Healthcare Provider Details

I. General information

NPI: 1235531336
Provider Name (Legal Business Name): SAMANTHA NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 09/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10948 RALEY CREEK DR S
JACKSONVILLE FL
32225-2324
US

IV. Provider business mailing address

10948 RALEY CREEK DR S
JACKSONVILLE FL
32225-2324
US

V. Phone/Fax

Practice location:
  • Phone: 904-888-2928
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberE3044177
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: