Provider Demographics
NPI:1316409642
Name:FLORESTAL, MARIE SAMANTHA (NP)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:SAMANTHA
Last Name:FLORESTAL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3975 S ORANGE BLOSSOM TRL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-7903
Mailing Address - Country:US
Mailing Address - Phone:407-864-1260
Mailing Address - Fax:
Practice Address - Street 1:3975 S ORANGE BLOSSOM TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32839-7903
Practice Address - Country:US
Practice Address - Phone:407-864-1260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11000144363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily