Provider Demographics
NPI:1861367542
Name:AMEZCUA, SAMANTHA MARIE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:AMEZCUA
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 1:863 N VAIL AVE
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-2432
Mailing Address - Country:US
Mailing Address - Phone:323-770-5452
Mailing Address - Fax:
Practice Address - Street 1:2101 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-4521
Practice Address - Country:US
Practice Address - Phone:562-218-1868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-10
Last Update Date:2025-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-QTHDYJ175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty