Provider Demographics
NPI:1801317086
Name:SAMUEL, DOROTHA LEE
Entity type:Individual
Prefix:
First Name:DOROTHA
Middle Name:LEE
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5850 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90003-1215
Mailing Address - Country:US
Mailing Address - Phone:323-897-6023
Mailing Address - Fax:323-846-4410
Practice Address - Street 1:5850 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-1215
Practice Address - Country:US
Practice Address - Phone:323-897-6023
Practice Address - Fax:323-846-4410
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN503189163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care