MEDICARE: MISS GWENDOLY IRINE SAMPSON CNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker	NA 08284758	TX

General Provider Information

NPI Number	:	1407189376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS GWENDOLY IRINE SAMPSON CNA

Provider Business Mailing Address
First Line	:	343 CAMPUS DR.
Second Line	:	PRIVATE HOME
City	:	DALLAS
State	:	TX
Zip	:	75217-7726
Country	:	US
Telephone Number	:	972-286-4327
Fax Number	:

Provider Business Practice Location Address
First Line	:	343 CAMPUS DR
Second Line	:	PRIVATE HOME
City	:	DALLAS
State	:	TX
Zip	:	75217-7726
Country	:	US
Telephone Number	:	972-286-4327
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2009
Last Update Date	:	09/10/2009

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