Healthcare Provider Details

I. General information

NPI: 1568096352
Provider Name (Legal Business Name): SAMANTHA JOSEPHINE PHILLIPS AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2020
Last Update Date: 11/27/2022
Certification Date: 11/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

685 RIVER AVE
LAKEWOOD NJ
08701-5288
US

IV. Provider business mailing address

24 ROSS RD
STANHOPE NJ
07874-3230
US

V. Phone/Fax

Practice location:
  • Phone: 732-486-7373
  • Fax:
Mailing address:
  • Phone: 908-307-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberAG02200160
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: