Provider Demographics
NPI:1083094544
Name:ROBERTSON, SAMANTHA NICOLE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:NICOLE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:250 S WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1134
Mailing Address - Country:US
Mailing Address - Phone:321-752-5210
Mailing Address - Fax:321-752-5388
Practice Address - Street 1:25 SILVER PALM AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3177
Practice Address - Country:US
Practice Address - Phone:321-752-5210
Practice Address - Fax:321-752-5388
Is Sole Proprietor?:No
Enumeration Date:2015-05-31
Last Update Date:2015-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9269583363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily