Healthcare Provider Details

I. General information

NPI: 1194234203
Provider Name (Legal Business Name): SAMANTHA KELLEY TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2017
Last Update Date: 09/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3053 KENNEDY BLVD
JERSEY CITY NJ
07306-3605
US

IV. Provider business mailing address

67 KENNEDY BLVD APT 2
BAYONNE NJ
07002-5235
US

V. Phone/Fax

Practice location:
  • Phone: 201-839-5380
  • Fax:
Mailing address:
  • Phone: 201-898-1268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number18KT00534500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: