Provider Demographics
NPI:1023551454
Name:SAM, KATHLEEN L (RNFA RN FIRST ASSIST)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:L
Last Name:SAM
Suffix:
Gender:F
Credentials:RNFA RN FIRST ASSIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 SHEPARD AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1952
Mailing Address - Country:US
Mailing Address - Phone:716-447-0204
Mailing Address - Fax:
Practice Address - Street 1:155 SHEPARD AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1952
Practice Address - Country:US
Practice Address - Phone:716-447-0204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-03
Last Update Date:2016-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321739-1163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant