Provider Demographics
NPI:1932507274
Name:SAM, CAROLINE E
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:E
Last Name:SAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 AIRPORT EXECUTIVE BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10958
Mailing Address - Country:US
Mailing Address - Phone:845-425-2655
Mailing Address - Fax:
Practice Address - Street 1:4215 GANNON LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-2914
Practice Address - Country:US
Practice Address - Phone:972-283-9090
Practice Address - Fax:972-499-0367
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-19
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1106805363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health