Provider Demographics
NPI:1922344845
Name:SAMUEL, GRACE (APN)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 CONCANNON DR
Mailing Address - Street 2:
Mailing Address - City:FORDS
Mailing Address - State:NJ
Mailing Address - Zip Code:08863-1322
Mailing Address - Country:US
Mailing Address - Phone:732-710-3314
Mailing Address - Fax:
Practice Address - Street 1:615 HOPE RD
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-1277
Practice Address - Country:US
Practice Address - Phone:732-571-1000
Practice Address - Fax:732-571-1156
Is Sole Proprietor?:No
Enumeration Date:2012-12-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00411300363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily