Provider Demographics
NPI:1508256918
Name:THEN, SAMANDY
Entity Type:Individual
Prefix:
First Name:SAMANDY
Middle Name:
Last Name:THEN
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 1:728 PUGSLEY AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10473-2005
Mailing Address - Country:US
Mailing Address - Phone:407-221-6627
Mailing Address - Fax:
Practice Address - Street 1:728 PUGSLEY AVE
Practice Address - Street 2:APT 1
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10473-2005
Practice Address - Country:US
Practice Address - Phone:407-221-6627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY908754433174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY17Medicaid