Provider Demographics
NPI:1578377107
Name:SAMUELSON, TAMMY ROSEMARY
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:ROSEMARY
Last Name:SAMUELSON
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 1:17130 SEQUOIA ST STE 104
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-1827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17130 SEQUOIA ST STE 104
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1827
Practice Address - Country:US
Practice Address - Phone:760-221-3970
Practice Address - Fax:760-221-3970
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker