Provider Demographics
NPI:1598021396
Name:SAMUEL, IRISDENE DOREEN (RN BSN)
Entity Type:Individual
Prefix:MISS
First Name:IRISDENE
Middle Name:DOREEN
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175-22 139TH ROAD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434
Mailing Address - Country:US
Mailing Address - Phone:718-525-0606
Mailing Address - Fax:
Practice Address - Street 1:175-22 139TH ROAD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434
Practice Address - Country:US
Practice Address - Phone:718-525-0606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY431150-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse