MEDICARE: MRS. JENNIFER M SAMGHABADI NP

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	363LF0000X	Family Nurse Practitioner	F336553	NY

General Provider Information

NPI Number	:	1881963502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER M SAMGHABADI NP

Provider Business Mailing Address
First Line	:	15 GARY ST
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-2805
Country	:	US
Telephone Number	:	631-241-1613
Fax Number	:

Provider Business Practice Location Address
First Line	:	15 GARY ST
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-2805
Country	:	US
Telephone Number	:	631-241-1613
Fax Number	:

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

Provider Enumeration Date	:	12/27/2011
Last Update Date	:	12/27/2011

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