Healthcare Provider Details

I. General information

NPI: 1700325834
Provider Name (Legal Business Name): SAMANTHA BROOKE CRICKMORE LM, CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2017
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 FOXBRIAR CV
JACKSONVILLE FL
32221-1508
US

IV. Provider business mailing address

728 FOXBRIAR CV
JACKSONVILLE FL
32221-1508
US

V. Phone/Fax

Practice location:
  • Phone: 352-278-4746
  • Fax:
Mailing address:
  • Phone: 352-278-4746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberMW306
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: