Basic Information
| Provider Information | |||||||||
| NPI: | 1801001128 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANDELLE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 GRAND ST | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061061541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605507500 | ||||||||
| FaxNumber: | 8602410890 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 GRAND ST | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061061541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605507500 | ||||||||
| FaxNumber: | 8602410890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 3516 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2200X | 3516 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | R173837 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 013358200 | 05 | CT | MEDICAID |