Healthcare Provider Details

I. General information

NPI: 1962318204
Provider Name (Legal Business Name): SAMANTHA DE VERA NP
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 N GILBERT ST BLDG B4
HEMET CA
92543-4078
US

IV. Provider business mailing address

255 N GILBERT ST BLDG B4
HEMET CA
92543-4078
US

V. Phone/Fax

Practice location:
  • Phone: 951-652-0060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number95039897
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: