Provider Demographics
NPI:1134329741
Name:SAMERDYKE, SUSAN M (APRN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:SAMERDYKE
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-652-4111
Mailing Address - Fax:239-652-4105
Practice Address - Street 1:13279 N CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:NORTH FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-4818
Practice Address - Country:US
Practice Address - Phone:239-652-4111
Practice Address - Fax:239-652-4105
Is Sole Proprietor?:No
Enumeration Date:2007-07-21
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN158152363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001586500Medicaid