Healthcare Provider Details

I. General information

NPI: 1801001128
Provider Name (Legal Business Name): MARY ANDELLE SAMSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 09/29/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 GRAND ST
HARTFORD CT
06106-1541
US

IV. Provider business mailing address

21 GRAND ST
HARTFORD CT
06106-1541
US

V. Phone/Fax

Practice location:
  • Phone: 860-550-7500
  • Fax: 860-241-0890
Mailing address:
  • Phone: 860-550-7500
  • Fax: 860-241-0890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR173837
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number3516
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number3516
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: