Provider Demographics
NPI:1568015766
Name:SAM, ANGELINA SENAM
Entity Type:Individual
Prefix:
First Name:ANGELINA
Middle Name:SENAM
Last Name:SAM
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 1:6281 OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2020
Mailing Address - Country:US
Mailing Address - Phone:651-200-0857
Mailing Address - Fax:651-200-3084
Practice Address - Street 1:6281 OAKWOOD RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2020
Practice Address - Country:US
Practice Address - Phone:651-200-0857
Practice Address - Fax:651-200-3084
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility