Healthcare Provider Details

I. General information

NPI: 1871796250
Provider Name (Legal Business Name): MS. SHERI LYNISE SAMUELS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 RESOURCE DR
RANDALLSTOWN MD
21133-4733
US

IV. Provider business mailing address

5307 CATALPHA RD
BALTIMORE MD
21214-1924
US

V. Phone/Fax

Practice location:
  • Phone: 410-887-0607
  • Fax: 410-496-9398
Mailing address:
  • Phone: 443-388-8712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberR149573
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: