Healthcare Provider Details

I. General information

NPI: 1629185020
Provider Name (Legal Business Name): MARIE MARGUERITE SAMPLE CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 IMPERIAL PL UNIT 2D
PROVIDENCE RI
02903-4642
US

IV. Provider business mailing address

455 TOLL GATE RD
WARWICK RI
02886-2759
US

V. Phone/Fax

Practice location:
  • Phone: 401-727-4800
  • Fax:
Mailing address:
  • Phone: 401-273-0641
  • Fax: 401-273-2919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number30769
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberCNM00178
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number11987
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: