Healthcare Provider Details

I. General information

NPI: 1508600859
Provider Name (Legal Business Name): SAMANTHA JANE SULLIVAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA JANE AVALOS

II. Dates (important events)

Enumeration Date: 06/21/2024
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3001
US

IV. Provider business mailing address

PO BOX 100288
GAINESVILLE FL
32610-0277
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-9079
  • Fax:
Mailing address:
  • Phone: 352-273-9079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11033413
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: