Provider Demographics
NPI:1508589359
Name:DIAZ-NASSAR, SAMANTHA ANDREA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANDREA
Last Name:DIAZ-NASSAR
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 1:148 LOMBARD CIR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-6525
Mailing Address - Country:US
Mailing Address - Phone:352-978-9041
Mailing Address - Fax:
Practice Address - Street 1:1200 N CENTRAL AVE STE 110
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4439
Practice Address - Country:US
Practice Address - Phone:407-530-5063
Practice Address - Fax:877-399-5578
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant