Healthcare Provider Details

I. General information

NPI: 1851065734
Provider Name (Legal Business Name): AILISH SAMUELSON PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 BROWNSKNOLL LN
EAGLE BRIDGE NY
12057-2307
US

IV. Provider business mailing address

18 BROWNSKNOLL LN
EAGLE BRIDGE NY
12057-2307
US

V. Phone/Fax

Practice location:
  • Phone: 518-290-0554
  • Fax:
Mailing address:
  • Phone: 518-919-3982
  • Fax: 479-334-3222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: