=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003290420
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA GOLDKLANG NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2015
-----------------------------------------------------
Last Update Date | 05/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 218 JAY ST
-----------------------------------------------------
City | WOOD-RIDGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-280-5232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 218 JAY ST
-----------------------------------------------------
City | WOOD-RIDGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-280-5232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 382612
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------