Provider Demographics
NPI:1134693773
Name:SAMANI, JACQUELINE LENT (RN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LENT
Last Name:SAMANI
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-361-5537
Mailing Address - Fax:
Practice Address - Street 1:220 N SYKES CREEK PKWY STE 301
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3490
Practice Address - Country:US
Practice Address - Phone:321-361-5537
Practice Address - Fax:321-361-5543
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9481192163W00000X
FLAPRN11009839363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNN820OtherFL MEDICARE