Provider Demographics
NPI:1851084172
Name:SAMUEL, PANSY L (NP)
Entity Type:Individual
Prefix:
First Name:PANSY
Middle Name:L
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:
Practice Address - Street 1:3950 HOLLYWOOD RD STE 110
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9151
Practice Address - Country:US
Practice Address - Phone:269-985-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704317910363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner