Provider Demographics
NPI:1184246472
Name:KYVIK, SAMANTHA LEE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEE
Last Name:KYVIK
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 1:147 LUDLAM RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-4534
Mailing Address - Country:US
Mailing Address - Phone:917-715-8978
Mailing Address - Fax:
Practice Address - Street 1:147 LUDLAM RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-4534
Practice Address - Country:US
Practice Address - Phone:917-715-8978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-11
Last Update Date:2020-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025434363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant