Provider Demographics
NPI:1275141954
Name:JOHNSON, SAMANTHA (APRN)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:SHIELDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1050 OLD CAMP RD STE 100
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-1762
Mailing Address - Country:US
Mailing Address - Phone:352-674-1760
Mailing Address - Fax:
Practice Address - Street 1:1050 OLD CAMP RD STE 100
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-1762
Practice Address - Country:US
Practice Address - Phone:352-674-1760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11008168363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily