Healthcare Provider Details

I. General information

NPI: 1134693773
Provider Name (Legal Business Name): JACQUELINE LENT SAMANI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2019
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N SYKES CREEK PKWY STE 301
MERRITT ISLAND FL
32953-3490
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-361-5537
  • Fax: 321-361-5543
Mailing address:
  • Phone: 321-361-5537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11009839
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9481192
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: