Healthcare Provider Details

I. General information

NPI: 1568934636
Provider Name (Legal Business Name): SAMANTHA LYNN MCNEILL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2018
Last Update Date: 02/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PRUDENTIAL DR
JACKSONVILLE FL
32207-8202
US

IV. Provider business mailing address

145 TERRACINA DR
ST AUGUSTINE FL
32092-4502
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-1364
  • Fax:
Mailing address:
  • Phone: 904-955-1886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11001070
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number122240
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: