Provider Demographics
NPI:1710116454
Name:SAM, MICHELINE (ARNP)
Entity Type:Individual
Prefix:
First Name:MICHELINE
Middle Name:
Last Name:SAM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 W ATLANTIC AVE
Mailing Address - Street 2:#D101 LAKE IDA MEDICAL CENTER
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33445
Mailing Address - Country:US
Mailing Address - Phone:561-279-0991
Mailing Address - Fax:561-279-0539
Practice Address - Street 1:2605 W ATLANTIC AVE
Practice Address - Street 2:#D101 LAKE IDA MEDICAL CENTER
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445
Practice Address - Country:US
Practice Address - Phone:561-279-0991
Practice Address - Fax:561-279-0539
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9192688363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner