Provider Demographics
NPI:1336998624
Name:SAMUELS, SIMONE (PMHNP)
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3038 PARKWAY BLVD APT 208
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34747-4525
Mailing Address - Country:US
Mailing Address - Phone:856-842-4047
Mailing Address - Fax:
Practice Address - Street 1:2959 ALAFAYA TRL STE 121
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9482
Practice Address - Country:US
Practice Address - Phone:239-690-6906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11030796363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health