Provider Demographics
NPI:1144096785
Name:SAMUEL, ANYA COLOTHA (PMHNP)
Entity type:Individual
Prefix:
First Name:ANYA
Middle Name:COLOTHA
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6444 FALCONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:NC
Mailing Address - Zip Code:27591-9653
Mailing Address - Country:US
Mailing Address - Phone:813-351-9086
Mailing Address - Fax:
Practice Address - Street 1:6444 FALCONWOOD DR
Practice Address - Street 2:
Practice Address - City:WENDELL
Practice Address - State:NC
Practice Address - Zip Code:27591-9653
Practice Address - Country:US
Practice Address - Phone:813-351-9086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2023128902363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty