Provider Demographics
NPI:1518234111
Name:SURACE, SAMANTHA DAWN (FAMILY NURSE PRACTIT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:DAWN
Last Name:SURACE
Suffix:
Gender:F
Credentials:FAMILY NURSE PRACTIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5380 TECH DATA DR STE 101
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-3122
Mailing Address - Country:US
Mailing Address - Phone:845-269-5740
Mailing Address - Fax:
Practice Address - Street 1:21 LOUISE DR
Practice Address - Street 2:
Practice Address - City:WEST NYACK
Practice Address - State:NY
Practice Address - Zip Code:10994-1911
Practice Address - Country:US
Practice Address - Phone:845-269-5740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-27
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY468023-1163W00000X
FLAPRN11007304363LF0000X, 363L00000X
NYF341222-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty