Healthcare Provider Details

I. General information

NPI: 1720600398
Provider Name (Legal Business Name): SAMANTHA WEINBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2020
Last Update Date: 11/02/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76-59 263RD STREET
GLEN OAKS NY
11004
US

IV. Provider business mailing address

7559 263RD ST
GLEN OAKS NY
11004-1100
US

V. Phone/Fax

Practice location:
  • Phone: 718-470-8100
  • Fax:
Mailing address:
  • Phone: 718-470-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number404551
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number716141
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: