Healthcare Provider Details

I. General information

NPI: 1770728354
Provider Name (Legal Business Name): MARYBETH SAMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2008
Last Update Date: 12/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST BULFINCH 127
BOSTON MA
02114-2621
US

IV. Provider business mailing address

55 FRUIT ST BULFINCH 127
BOSTON MA
02114-2621
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-3772
  • Fax:
Mailing address:
  • Phone: 617-726-3772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number186882
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: