MEDICARE: SAMANTHA LAINE SIMON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	APRN11041627	FL
2	363LF0000X	Family Nurse Practitioner	APRN11041627	FL

General Provider Information

NPI Number	:	1548112014
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA LAINE SIMON

Provider Business Mailing Address
First Line	:	PO BOX 746638
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-6638
Country	:	US
Telephone Number	:	904-202-2092
Fax Number	:	904-376-4075

Provider Business Practice Location Address
First Line	:	532 RIVERSIDE AVE STE 103
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32202-4914
Country	:	US
Telephone Number	:	904-353-5696
Fax Number	:	904-390-7483

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2026
Last Update Date	:	05/22/2026

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Directions to “ SAMANTHA LAINE SIMON ” Practice Location

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