Provider Demographics
NPI:1841888773
Name:GULLETT, SAMANTHA (ATC, LAT, OTC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GULLETT
Suffix:
Gender:F
Credentials:ATC, LAT, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4490 PORTOFINO WAY APT 307
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-8100
Mailing Address - Country:US
Mailing Address - Phone:954-830-2776
Mailing Address - Fax:
Practice Address - Street 1:4560 LANTANA RD STE 100
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-6998
Practice Address - Country:US
Practice Address - Phone:561-967-4400
Practice Address - Fax:844-959-0419
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL55592255A2300X
FL201116246ZX2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZX2200XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherOrthopedic Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer