Provider Demographics
NPI:1932707932
Name:AMENDOLA, SAMANTHA ROSE (NP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ROSE
Last Name:AMENDOLA
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 1:325 EDELWEISS RD
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-2805
Mailing Address - Country:US
Mailing Address - Phone:631-860-3581
Mailing Address - Fax:
Practice Address - Street 1:400 POTTER BLVD
Practice Address - Street 2:
Practice Address - City:BRIGHTWATERS
Practice Address - State:NY
Practice Address - Zip Code:11718
Practice Address - Country:US
Practice Address - Phone:631-591-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309887363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY309887OtherNYS NP LICENSE NUMBER