Healthcare Provider Details

I. General information

NPI: 1285381343
Provider Name (Legal Business Name): SAMANTHA ROSE KOLIOS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2022
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MAR WALT DR
FORT WALTON BEACH FL
32547-6708
US

IV. Provider business mailing address

1000 MAR WALT DR
FORT WALTON BEACH FL
32547-6708
US

V. Phone/Fax

Practice location:
  • Phone: 850-864-0269
  • Fax: 850-862-1839
Mailing address:
  • Phone: 850-864-0269
  • Fax: 850-862-1839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number233982
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10672
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11019228
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9646206
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number157401
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: