Provider Demographics
NPI:1417429523
Name:VICKERS, SAMANTHA JUANITA (DNP, CRNA)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:JUANITA
Last Name:VICKERS
Suffix:
Gender:F
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:47 LOGGERHEAD LN
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2585
Mailing Address - Country:US
Mailing Address - Phone:315-651-0047
Mailing Address - Fax:
Practice Address - Street 1:3625 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4207
Practice Address - Country:US
Practice Address - Phone:904-702-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-31
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11000749367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered