Provider Demographics
NPI:1427580323
Name:NICOTRA, SAMANTHA ELIZABETH
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:ELIZABETH
Last Name:NICOTRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2609 SE 21ST PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-3275
Mailing Address - Country:US
Mailing Address - Phone:239-464-5749
Mailing Address - Fax:
Practice Address - Street 1:14391 METROPOLIS AVE STE 101102
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4423
Practice Address - Country:US
Practice Address - Phone:239-464-5749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
FL30412355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist