Provider Demographics
NPI:1457998338
Name:SAMPSON, KENYATTE RASHEND JR
Entity Type:Individual
Prefix:
First Name:KENYATTE
Middle Name:RASHEND
Last Name:SAMPSON
Suffix:JR
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 1:3113 W DAKOTA ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19132-3313
Mailing Address - Country:US
Mailing Address - Phone:856-842-6493
Mailing Address - Fax:
Practice Address - Street 1:3009 W FLETCHER ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132-3427
Practice Address - Country:US
Practice Address - Phone:856-842-6493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty