Healthcare Provider Details

I. General information

NPI: 1285269068
Provider Name (Legal Business Name): AMYLEE MICHELLE SAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMYLEE MICHELLE MARTIN MD

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24887 TAYLOR ST BLDG SUITE202
LOMA LINDA CA
92350-0225
US

IV. Provider business mailing address

24887 TAYLOR ST BLDG SUITE202
LOMA LINDA CA
92350-0225
US

V. Phone/Fax

Practice location:
  • Phone: 909-651-4024
  • Fax:
Mailing address:
  • Phone: 909-558-6131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA188030
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: