Provider Demographics
NPI:1821557422
Name:WALAS, SAMANTHA JAYNE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JAYNE
Last Name:WALAS
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 1:16 SANBORN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-3818
Mailing Address - Country:US
Mailing Address - Phone:617-218-1043
Mailing Address - Fax:
Practice Address - Street 1:151 JEROME ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3534
Practice Address - Country:US
Practice Address - Phone:413-218-1043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2309155163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health