Healthcare Provider Details

I. General information

NPI: 1497675698
Provider Name (Legal Business Name): SAMANTHA HERTZMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA AVILA

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E MAIN ST
BAY SHORE NY
11706-8408
US

IV. Provider business mailing address

562 S 14TH ST
LINDENHURST NY
11757-4438
US

V. Phone/Fax

Practice location:
  • Phone: 631-968-3162
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number691909
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: