Provider Demographics
NPI:1336815984
Name:BREITBART, SAMANTHA (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BREITBART
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 MEADOWBROOK RD
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-3800
Mailing Address - Country:US
Mailing Address - Phone:862-812-9624
Mailing Address - Fax:
Practice Address - Street 1:338 UNION AVE
Practice Address - Street 2:
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070-1563
Practice Address - Country:US
Practice Address - Phone:201-842-0501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01191900363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics