Provider Demographics
NPI:1720766819
Name:SAMPANG, MARY GRACE
Entity Type:Individual
Prefix:
First Name:MARY GRACE
Middle Name:
Last Name:SAMPANG
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 1:9331 APHRODITE DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-1493
Mailing Address - Country:US
Mailing Address - Phone:907-222-4037
Mailing Address - Fax:
Practice Address - Street 1:9331 APHRODITE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-1493
Practice Address - Country:US
Practice Address - Phone:907-222-4037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101557310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility