Provider Demographics
NPI:1619429172
Name:SAMUEL-NINOU, ALICIA (BS, MMP)
Entity Type:Individual
Prefix:MS
First Name:ALICIA
Middle Name:
Last Name:SAMUEL-NINOU
Suffix:
Gender:F
Credentials:BS, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 N GOLDENROD RD
Mailing Address - Street 2:#135
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32807-8365
Mailing Address - Country:US
Mailing Address - Phone:321-512-1320
Mailing Address - Fax:
Practice Address - Street 1:1460 N GOLDENROD RD
Practice Address - Street 2:#135
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-8365
Practice Address - Country:US
Practice Address - Phone:321-512-1320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 74765225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist