Provider Demographics
NPI:1851776488
Name:SAMUDA, TANISHA (RN)
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:SAMUDA
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 1:230 LOTT AVE
Mailing Address - Street 2:APT. 2J
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-5821
Mailing Address - Country:US
Mailing Address - Phone:347-938-6924
Mailing Address - Fax:347-350-7421
Practice Address - Street 1:230 LOTT AVE
Practice Address - Street 2:APT. 2J
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-5821
Practice Address - Country:US
Practice Address - Phone:347-938-6924
Practice Address - Fax:347-350-7421
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY690740163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse