Healthcare Provider Details

I. General information

NPI: 1588116008
Provider Name (Legal Business Name): REBECCA SAMPLES PUGMIRE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECCA DIANE SAMPLES NP

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRESHAM DR STE 8620
NORFOLK VA
23507-1904
US

IV. Provider business mailing address

600 GRESHAM DR STE 8620
NORFOLK VA
23507-1904
US

V. Phone/Fax

Practice location:
  • Phone: 757-395-1600
  • Fax: 757-625-0433
Mailing address:
  • Phone: 757-395-1600
  • Fax: 757-625-0433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024174130
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: