Provider Demographics
NPI:1104079995
Name:VICK, SAMANTHA (ARNP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:VICK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2906 N 35TH TER
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-8406
Mailing Address - Country:US
Mailing Address - Phone:954-612-6857
Mailing Address - Fax:
Practice Address - Street 1:2906 N 35TH TER
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-8406
Practice Address - Country:US
Practice Address - Phone:954-612-6857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-24
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9186588363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001877200Medicaid
FLBB168UMedicare PIN
FLBB168ZMedicare UPIN
FL001877200Medicaid