Provider Demographics
NPI:1457907586
Name:SAMPSON, ROBERT L (CNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:SAMPSON
Suffix:
Gender:M
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:PAWNEE
Mailing Address - State:IL
Mailing Address - Zip Code:62558-9152
Mailing Address - Country:US
Mailing Address - Phone:217-303-1265
Mailing Address - Fax:
Practice Address - Street 1:813 CARROLL ST
Practice Address - Street 2:
Practice Address - City:PAWNEE
Practice Address - State:IL
Practice Address - Zip Code:62558-9152
Practice Address - Country:US
Practice Address - Phone:217-303-1265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILS512-7726-7037OtherDRIVERS LICENSE