Healthcare Provider Details

I. General information

NPI: 1356036669
Provider Name (Legal Business Name): SAMANTHA KATE PETTIGREW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 N CLYDE MORRIS BLVD
DAYTONA BEACH FL
32114-2709
US

IV. Provider business mailing address

1620 DELPHI WAY
NEW SMYRNA BEACH FL
32168-9363
US

V. Phone/Fax

Practice location:
  • Phone: 386-270-8202
  • Fax:
Mailing address:
  • Phone: 307-421-9378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME183197
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: