Provider Demographics
NPI:1821633868
Name:CHANG, SAMANTHA (RN)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 HAPPY ACRES DR
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-3015
Mailing Address - Country:US
Mailing Address - Phone:631-605-9006
Mailing Address - Fax:
Practice Address - Street 1:10 HAPPY ACRES DR
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-3015
Practice Address - Country:US
Practice Address - Phone:631-605-9006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY414605146N00000X
NY760221163WN0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic