Provider Demographics
NPI:1053694125
Name:MENDEZ, JORLY ANNE SAMSON (RN)
Entity type:Individual
Prefix:
First Name:JORLY ANNE
Middle Name:SAMSON
Last Name:MENDEZ
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 SOMERSET ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-8421
Mailing Address - Country:US
Mailing Address - Phone:631-520-8304
Mailing Address - Fax:
Practice Address - Street 1:43 SOMERSET ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-8421
Practice Address - Country:US
Practice Address - Phone:631-520-8304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-24
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY646635163WP0200X, 163W00000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163W00000XNursing Service ProvidersRegistered Nurse