Healthcare Provider Details

I. General information

NPI: 1306329123
Provider Name (Legal Business Name): SAMANTHA MARIE HOUSE PMHNP, RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2018
Last Update Date: 01/01/2025
Certification Date: 01/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 ERIE BLVD W
SYRACUSE NY
13204-2445
US

IV. Provider business mailing address

620 ERIE BLVD W STE 302
SYRACUSE NY
13204-2463
US

V. Phone/Fax

Practice location:
  • Phone: 315-472-7363
  • Fax: 315-472-0084
Mailing address:
  • Phone: 315-472-7363
  • Fax: 315-472-0084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number532811
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF405062-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: