Provider Demographics
NPI:1790123784
Name:SAMUEL, ANISHA
Entity Type:Individual
Prefix:
First Name:ANISHA
Middle Name:
Last Name:SAMUEL
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 1:10460 QUEENS BLVD
Mailing Address - Street 2:APT 16C
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-7318
Mailing Address - Country:US
Mailing Address - Phone:516-451-5658
Mailing Address - Fax:
Practice Address - Street 1:10460 QUEENS BLVD
Practice Address - Street 2:APT 16C
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7318
Practice Address - Country:US
Practice Address - Phone:516-451-5658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY312268164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse