Provider Demographics
NPI:1801001128
Name:SAMSON, MARY ANDELLE (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANDELLE
Last Name:SAMSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-1541
Mailing Address - Country:US
Mailing Address - Phone:860-550-7500
Mailing Address - Fax:860-241-0890
Practice Address - Street 1:21 GRAND ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-1541
Practice Address - Country:US
Practice Address - Phone:860-550-7500
Practice Address - Fax:860-241-0890
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3516363LA2100X, 363LA2200X
MDR173837363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT013358200Medicaid
CTKS04 Q929Medicare PIN