Provider Demographics
NPI:1396619466
Name:MUSKELLY, SAMUEL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:MUSKELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:767 PROVIDENCE ST
Mailing Address - Street 2:
Mailing Address - City:WEST WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02893-1526
Mailing Address - Country:US
Mailing Address - Phone:401-743-0271
Mailing Address - Fax:
Practice Address - Street 1:767 PROVIDENCE ST
Practice Address - Street 2:
Practice Address - City:WEST WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02893-1526
Practice Address - Country:US
Practice Address - Phone:401-743-0271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-01
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker