Provider Demographics
NPI:1447076526
Name:JEFFERSON, SAMANTHA LORRAINE KIRK (CPNP-PC)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:LORRAINE KIRK
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7917 W RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-3825
Mailing Address - Country:US
Mailing Address - Phone:301-219-7477
Mailing Address - Fax:
Practice Address - Street 1:251 NAJOLES RD
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-2519
Practice Address - Country:US
Practice Address - Phone:410-729-0690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-23
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR228455363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD197364900Medicaid