Provider Demographics
NPI:1689234692
Name:HENSLEY, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:HENSLEY
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:PO BOX 1255
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-0902
Mailing Address - Country:US
Mailing Address - Phone:631-508-3758
Mailing Address - Fax:
Practice Address - Street 1:361 JUNE AVE
Practice Address - Street 2:
Practice Address - City:FLANDERS
Practice Address - State:NY
Practice Address - Zip Code:11901-4340
Practice Address - Country:US
Practice Address - Phone:631-508-3788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY333461-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse