Provider Demographics
NPI:1265621866
Name:SAMUELS, JENNIFER LEE (RN, MSN, CPNP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEE
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:RN, MSN, CPNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:SHAFFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, MSN, CPNP
Mailing Address - Street 1:7975 N HAYDEN RD
Mailing Address - Street 2:STE D354
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-3243
Mailing Address - Country:US
Mailing Address - Phone:323-361-3550
Mailing Address - Fax:
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-361-5162
Practice Address - Fax:323-361-3717
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95075527363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95075527OtherSTATE LICENSE