Provider Demographics
NPI:1063217032
Name:VICENCIO, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:VICENCIO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 NEW SCOTLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208
Mailing Address - Country:US
Mailing Address - Phone:518-262-6455
Mailing Address - Fax:
Practice Address - Street 1:43 NEW SCOTLAND AVENUE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208
Practice Address - Country:US
Practice Address - Phone:518-262-6455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-14
Last Update Date:2025-04-18
Deactivation Date:2025-03-17
Deactivation Code:
Reactivation Date:2025-04-16
Provider Licenses
StateLicense IDTaxonomies
390200000X
65175390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program