Healthcare Provider Details

I. General information

NPI: 1598585218
Provider Name (Legal Business Name): SAMANTHA THERESE HEFFERNAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2024
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 HOPKINS AVE APT 3
JERSEY CITY NJ
07306-2149
US

IV. Provider business mailing address

104 HOPKINS AVE APT 3
JERSEY CITY NJ
07306-2149
US

V. Phone/Fax

Practice location:
  • Phone: 714-469-0980
  • Fax:
Mailing address:
  • Phone: 714-469-0980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ15145000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: