Provider Demographics
NPI:1750047908
Name:AVILA, SAMANTHA NICOLE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:NICOLE
Last Name:AVILA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12021 WILMINGTON AVE STE 2B
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059-3019
Mailing Address - Country:US
Mailing Address - Phone:310-221-6336
Mailing Address - Fax:
Practice Address - Street 1:12021 WILMINGTON AVE STE 2B
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3019
Practice Address - Country:US
Practice Address - Phone:310-221-6336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALVN715326164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse