Provider Demographics
NPI:1043984339
Name:SAMUEL, JASMINE (FNP)
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4041 N CENTRAL AVE BLDG C
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-3313
Mailing Address - Country:US
Mailing Address - Phone:602-279-5262
Mailing Address - Fax:
Practice Address - Street 1:4041 N CENTRAL AVE BLDG C
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-3313
Practice Address - Country:US
Practice Address - Phone:602-279-5262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ254314363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily