Provider Demographics
NPI:1629185020
Name:SAMPLE, MARIE MARGUERITE (CNM)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:MARGUERITE
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 IMPERIAL PL UNIT 2D
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4642
Mailing Address - Country:US
Mailing Address - Phone:401-727-4800
Mailing Address - Fax:
Practice Address - Street 1:18 IMPERIAL PL UNIT 2D
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4642
Practice Address - Country:US
Practice Address - Phone:401-727-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11987367A00000X
RICNM00178367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA726695410AMedicaid
GA582369659OtherPRIVATE INS COMPANIES
GA726695410AMedicaid