Provider Demographics
NPI:1700408762
Name:FERAZZOLI, SAMANTHA M
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:M
Last Name:FERAZZOLI
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 1:207 GLEN COVE AVE
Mailing Address - Street 2:
Mailing Address - City:SEA CLIFF
Mailing Address - State:NY
Mailing Address - Zip Code:11579-1455
Mailing Address - Country:US
Mailing Address - Phone:516-592-9577
Mailing Address - Fax:
Practice Address - Street 1:207 GLEN COVE AVE
Practice Address - Street 2:
Practice Address - City:SEA CLIFF
Practice Address - State:NY
Practice Address - Zip Code:11579-1455
Practice Address - Country:US
Practice Address - Phone:516-676-1742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY672200163W00000X
NY309884363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse