Provider Demographics
NPI:1639834492
Name:EBERT, SAMANTHA (RN)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:EBERT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 GOLDEN SKY WAY UNIT 158
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-8845
Mailing Address - Country:US
Mailing Address - Phone:949-690-0638
Mailing Address - Fax:
Practice Address - Street 1:507 TELEGRAPH CANYON RD
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-6436
Practice Address - Country:US
Practice Address - Phone:161-942-1298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95214747163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty