Provider Demographics
NPI:1821883661
Name:WAHL, SAMANTHA (AGNP-C)
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:
Last Name:WAHL
Suffix:
Gender:
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22331
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34276-5331
Mailing Address - Country:US
Mailing Address - Phone:941-914-2036
Mailing Address - Fax:
Practice Address - Street 1:4001 SWIFT RD.
Practice Address - Street 2:SUITE 2
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231
Practice Address - Country:US
Practice Address - Phone:941-350-8568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-11
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11038776363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology