Healthcare Provider Details

I. General information

NPI: 1194405209
Provider Name (Legal Business Name): SAMUEL SPEIGHTS PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8977 MIRA MESA BLVD
SAN DIEGO CA
92126-2716
US

IV. Provider business mailing address

637 3RD AVE STE E1
CHULA VISTA CA
91910-5707
US

V. Phone/Fax

Practice location:
  • Phone: 844-200-2426
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95030582
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: