=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821500141
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA LEIGH SYLVIA NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2017
-----------------------------------------------------
Last Update Date | 01/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 568 RUIN CREEK RD STE 6
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27536-5921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-476-4869
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 71 HEDRICK DR
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27537-6292
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-476-4869
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 9362642
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 5011643
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------