Provider Demographics
NPI:1336801596
Name:MCCRORY, SAMANTHA MACKENZIE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MACKENZIE
Last Name:MCCRORY
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 1:179 SEAMAN RD
Mailing Address - Street 2:
Mailing Address - City:STORMVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12582-5111
Mailing Address - Country:US
Mailing Address - Phone:845-240-4464
Mailing Address - Fax:
Practice Address - Street 1:179 SEAMAN RD
Practice Address - Street 2:
Practice Address - City:STORMVILLE
Practice Address - State:NY
Practice Address - Zip Code:12582-5111
Practice Address - Country:US
Practice Address - Phone:845-240-4464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY775956163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics