Provider Demographics
NPI:1780068494
Name:CLARKE, SAMANTHA FENNELLA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:FENNELLA
Last Name:CLARKE
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 1:15 ISABELLA AVE APT. 3R
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002
Mailing Address - Country:US
Mailing Address - Phone:347-357-3666
Mailing Address - Fax:
Practice Address - Street 1:15 ISABELLA AVE APT 3R
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-4373
Practice Address - Country:US
Practice Address - Phone:347-357-3666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY248896164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse