Provider Demographics
NPI:1285269068
Name:SAM, AMYLEE MICHELLE
Entity type:Individual
Prefix:
First Name:AMYLEE
Middle Name:MICHELLE
Last Name:SAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMYLEE
Other - Middle Name:MICHELLE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4510 BROCKTON AVE STE 253
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4020
Mailing Address - Country:US
Mailing Address - Phone:951-897-9896
Mailing Address - Fax:
Practice Address - Street 1:197 E CAROLINE ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3729
Practice Address - Country:US
Practice Address - Phone:909-651-4024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program