Provider Demographics
NPI:1023248630
Name:STREET, SAMANTHA GAIL (RN,FA,CNOR)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:GAIL
Last Name:STREET
Suffix:
Gender:F
Credentials:RN,FA,CNOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1000 DEPT 245
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-761-9030
Mailing Address - Fax:901-473-6505
Practice Address - Street 1:80 HUMPHREYS CTR STE 100
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2352
Practice Address - Country:US
Practice Address - Phone:901-761-9030
Practice Address - Fax:901-473-6505
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-16
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000152703163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
085478OtherRN, CNOR
TNRN0000152703OtherRN LICENSE