Provider Demographics
NPI:1598585218
Name:HEFFERNAN, SAMANTHA THERESE (NP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:THERESE
Last Name:HEFFERNAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 HOPKINS AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-2149
Mailing Address - Country:US
Mailing Address - Phone:714-469-0980
Mailing Address - Fax:
Practice Address - Street 1:104 HOPKINS AVE APT 3
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-2149
Practice Address - Country:US
Practice Address - Phone:714-469-0980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15145000363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner