Provider Demographics
NPI:1316276298
Name:SAMUEL, AYESHA FATIN (LPN)
Entity type:Individual
Prefix:
First Name:AYESHA
Middle Name:FATIN
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 E DELAVAN AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14208-1234
Mailing Address - Country:US
Mailing Address - Phone:716-939-2076
Mailing Address - Fax:
Practice Address - Street 1:193 E DELAVAN AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14208-1234
Practice Address - Country:US
Practice Address - Phone:716-939-2076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY254115164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse