1104402361 NPI number — SAMANTHA ROSE KHUNDMIRI RN, APNP

Table of content: SAMANTHA ROSE KHUNDMIRI RN, APNP (NPI 1104402361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104402361 NPI number — SAMANTHA ROSE KHUNDMIRI RN, APNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHUNDMIRI
Provider First Name:
SAMANTHA
Provider Middle Name:
ROSE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, APNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HARRIS
Provider Other First Name:
SAMANTHA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104402361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6220 W LOOMIS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENDALE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53129-2448
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-423-0555
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6220 W LOOMIS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENDALE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53129-2448
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-423-0555
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/19/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  11302-33 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163W00000X , with the licence number: 230241-30 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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