Provider Demographics
NPI:1063597250
Name:SAMUEL, LOLETA C (NP)
Entity type:Individual
Prefix:
First Name:LOLETA
Middle Name:C
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LOLETA
Other - Middle Name:C
Other - Last Name:SAMUEL-O'GARRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:50 S B B KING BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2626
Mailing Address - Country:US
Mailing Address - Phone:901-436-1381
Mailing Address - Fax:
Practice Address - Street 1:195 LITTLE ALBANY ST
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1914
Practice Address - Country:US
Practice Address - Phone:732-235-2465
Practice Address - Fax:732-235-7355
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN108625163W00000X, 363L00000X
NJ26NN10862500363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8429502Medicaid
NJ8429502Medicaid
NJP26359Medicare UPIN
046057Medicare PIN