Provider Demographics
NPI:1184949620
Name:SAMUELS, KEENA S (ANP)
Entity type:Individual
Prefix:MRS
First Name:KEENA
Middle Name:S
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20507 HILLSIDE AVE
Mailing Address - Street 2:SUITE #28
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-2222
Mailing Address - Country:US
Mailing Address - Phone:917-574-1655
Mailing Address - Fax:
Practice Address - Street 1:20507 HILLSIDE AVE
Practice Address - Street 2:SUITE #28
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-2222
Practice Address - Country:US
Practice Address - Phone:917-574-1655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-27
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305351363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health