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General NPI Number Information
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NPI Number | 1659962363
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Entity Type | Individual
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Provider Name | SAMANTHA ERVIN APRN
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Gender | Female
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Dates
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Enumeration Date | 01/27/2021
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Last Update Date | 01/27/2021
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Provider Practice Location Address
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Address Line | 1000 MAR WALT DR
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-6708
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Country | US
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Telephone | 850-572-9447
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Fax |
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Provider Business Mailing Address
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Address Line | 2651 PLEASANT VALLEY DR
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City | CANTONMENT
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State | FL
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Zip | 32533-5719
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Country | US
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Telephone | 850-572-9447
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | APRN11011308
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License Number State | FL
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