Provider Demographics
NPI:1629750112
Name:GWINN, SAMANTHA GAYLE (LMT, CNA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:GAYLE
Last Name:GWINN
Suffix:
Gender:F
Credentials:LMT, CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1366 E GARON CV
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:FL
Mailing Address - Zip Code:32732-8818
Mailing Address - Country:US
Mailing Address - Phone:386-675-8368
Mailing Address - Fax:
Practice Address - Street 1:1954 W STATE RD 426
Practice Address - Street 2:SUITE 1124, STUDIO #13
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765
Practice Address - Country:US
Practice Address - Phone:386-675-8368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA90619225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty