Provider Demographics
NPI:1912612763
Name:SAMUELS, COURTNEY TIEREE (APRN)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:TIEREE
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:2205 GREENTREE N
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-8957
Practice Address - Country:US
Practice Address - Phone:812-218-6560
Practice Address - Fax:812-288-2605
Is Sole Proprietor?:No
Enumeration Date:2023-01-17
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3018888363LF0000X
IN71013451A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71013451AOtherSTATE LICENSE
KY3018888OtherSTATE LICENSE
IN300072891Medicaid
KY7100954570Medicaid