Healthcare Provider Details

I. General information

NPI: 1942729090
Provider Name (Legal Business Name): SAMANTHA AVLA BLUE DNP, APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA A BLUE RN

II. Dates (important events)

Enumeration Date: 09/10/2017
Last Update Date: 09/16/2023
Certification Date: 09/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15415 PANAMA CITY BEACH PKWY
PANAMA CITY BEACH FL
32413-5409
US

IV. Provider business mailing address

15415 PANAMA CITY BEACH PKWY
PANAMA CITY BEACH FL
32413-5409
US

V. Phone/Fax

Practice location:
  • Phone: 850-583-9747
  • Fax:
Mailing address:
  • Phone: 850-588-3589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number26NR14129300
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9487688
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: