Provider Demographics
NPI:1922690577
Name:PESZKO, SAMANTHA JOANNE (NP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JOANNE
Last Name:PESZKO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1865
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:3601 W 13 MILE RD STE EC
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-898-5058
Practice Address - Fax:248-898-2017
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2022-07-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4704320253163W00000X, 363LF0000X
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program