Healthcare Provider Details

I. General information

NPI: 1548112014
Provider Name (Legal Business Name): SAMANTHA LAINE SIMON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 RIVERSIDE AVE STE 103
JACKSONVILLE FL
32202-4914
US

IV. Provider business mailing address

PO BOX 746638
ATLANTA GA
30374-6638
US

V. Phone/Fax

Practice location:
  • Phone: 904-353-5696
  • Fax: 904-390-7483
Mailing address:
  • Phone: 904-202-2092
  • Fax: 904-376-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11041627
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11041627
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: