Provider Demographics
NPI:1104153964
Name:SAM, ALICE (LPN)
Entity type:Individual
Prefix:MS
First Name:ALICE
Middle Name:
Last Name:SAM
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 1:215 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-5229
Mailing Address - Country:US
Mailing Address - Phone:516-492-2975
Mailing Address - Fax:516-492-2975
Practice Address - Street 1:215 CEDAR ST
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-5229
Practice Address - Country:US
Practice Address - Phone:516-492-2975
Practice Address - Fax:516-492-2975
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-14
Last Update Date:2009-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186770-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01543700Medicaid