Basic Information
| Provider Information | |||||||||
| NPI: | 1538773783 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WADDELL | ||||||||
| FirstName: | SAMANTHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3378 MARINER BLVD | ||||||||
| Address2: | |||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346092460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527967171 | ||||||||
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| Practice Location | |||||||||
| Address1: | 130 PABLO ST | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338033818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632846800 | ||||||||
| FaxNumber: | 8636871033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2020 | ||||||||
| LastUpdateDate: | 08/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 11009125 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1538773783 | 05 | FL | MEDICAID |