Provider Demographics
NPI:1497425326
Name:GREENWALD, SAMANTHA LARUE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LARUE
Last Name:GREENWALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 DELAWARE DR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2368
Mailing Address - Country:US
Mailing Address - Phone:630-991-8556
Mailing Address - Fax:
Practice Address - Street 1:126 DELAWARE DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2368
Practice Address - Country:US
Practice Address - Phone:630-991-8556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041430338163W00000X
IL144316367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse