Provider Demographics
NPI:1952872681
Name:BOURSIQUOT, SAMANTA (LPN)
Entity Type:Individual
Prefix:
First Name:SAMANTA
Middle Name:
Last Name:BOURSIQUOT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 BISMARK AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-1455
Mailing Address - Country:US
Mailing Address - Phone:516-263-4467
Mailing Address - Fax:
Practice Address - Street 1:7 BISMARK AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-1455
Practice Address - Country:US
Practice Address - Phone:516-263-4467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY328485164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse