Provider Demographics
NPI:1891684783
Name:GILLAM, SAMANTHA LYNN (APRN)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNN
Last Name:GILLAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5132 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-8607
Mailing Address - Country:US
Mailing Address - Phone:704-798-0619
Mailing Address - Fax:
Practice Address - Street 1:5132 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-8607
Practice Address - Country:US
Practice Address - Phone:704-798-0619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-02
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11040193363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner