Provider Demographics
NPI:1093361099
Name:AZAM, SAMANTHA MARIE (FNP)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:MARIE
Last Name:AZAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13630 SUMMER RAIN DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7447
Mailing Address - Country:US
Mailing Address - Phone:407-923-0999
Mailing Address - Fax:
Practice Address - Street 1:925 S SEMORAN BLVD STE 110A
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-5313
Practice Address - Country:US
Practice Address - Phone:407-961-6834
Practice Address - Fax:866-364-7259
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11002816363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner