Provider Demographics
NPI:1215241708
Name:SAMPSON, ANNETTE N
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:N
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9615 GRAND RONDE RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RONDE
Mailing Address - State:OR
Mailing Address - Zip Code:97347-9712
Mailing Address - Country:US
Mailing Address - Phone:503-879-2002
Mailing Address - Fax:
Practice Address - Street 1:9605 GRAND RONDE RD
Practice Address - Street 2:
Practice Address - City:GRAND RONDE
Practice Address - State:OR
Practice Address - Zip Code:97347-9712
Practice Address - Country:US
Practice Address - Phone:503-879-2002
Practice Address - Fax:503-879-2071
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201141804RN163W00000X
OR202214454NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR171037Medicaid