Provider Demographics
NPI:1679199269
Name:SAMPSON, LISA NICOLE (LICENSED CPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:NICOLE
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:LICENSED CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 BEAUFORT AVE # B
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-1309
Mailing Address - Country:US
Mailing Address - Phone:562-230-5108
Mailing Address - Fax:
Practice Address - Street 1:2413 BEAUFORT AVE # B
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-1309
Practice Address - Country:US
Practice Address - Phone:562-230-5108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-19
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPT35358251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health