Healthcare Provider Details

I. General information

NPI: 1669057014
Provider Name (Legal Business Name): JISSEL SAMONS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 DON WICKHAM DR
CLERMONT FL
34711-1979
US

IV. Provider business mailing address

19375 RANCH CLUB BLVD
GROVELAND FL
34736-8454
US

V. Phone/Fax

Practice location:
  • Phone: 352-394-4071
  • Fax:
Mailing address:
  • Phone: 352-321-6102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11046660
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28264469A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: