Healthcare Provider Details

I. General information

NPI: 1508589359
Provider Name (Legal Business Name): SAMANTHA ANDREA DIAZ-NASSAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 09/26/2022
Certification Date: 09/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N CENTRAL AVE STE 110
KISSIMMEE FL
34741-4439
US

IV. Provider business mailing address

148 LOMBARD CIR
CLERMONT FL
34711-6525
US

V. Phone/Fax

Practice location:
  • Phone: 407-530-5063
  • Fax: 877-399-5578
Mailing address:
  • Phone: 352-978-9041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: