Provider Demographics
NPI:1982991451
Name:POLIDORO, SAMANTHA JOSEPHINE (LPN)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JOSEPHINE
Last Name:POLIDORO
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 ANGELA LN
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-1307
Mailing Address - Country:US
Mailing Address - Phone:631-346-5541
Mailing Address - Fax:
Practice Address - Street 1:7 ANGELA LN
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-1307
Practice Address - Country:US
Practice Address - Phone:631-346-5541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305912164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse