Healthcare Provider Details

I. General information

NPI: 1518234111
Provider Name (Legal Business Name): SAMANTHA DAWN SURACE FAMILY NURSE PRACTIT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2011
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2776 CLEVELAND AVE
FORT MYERS FL
33901-5864
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-1614
  • Fax: 239-343-3695
Mailing address:
  • Phone: 239-343-1614
  • Fax: 239-343-3695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11007304
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11007304
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number468023-1
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF341222-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: