Provider Demographics
NPI:1558964833
Name:SAMUEL, PREETHA (CRNA)
Entity Type:Individual
Prefix:
First Name:PREETHA
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13444 NW 13TH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-2718
Mailing Address - Country:US
Mailing Address - Phone:305-746-7794
Mailing Address - Fax:
Practice Address - Street 1:401 NW 42ND AVE
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2835
Practice Address - Country:US
Practice Address - Phone:954-587-5010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2021-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11011610367500000X
FLAPRN11011610367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1558964833Medicaid