Provider Demographics
NPI:1649159377
Name:JOHNSON, SAMANTHA SHALIA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:SHALIA
Last Name:JOHNSON
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 1:1174 S HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-6440
Mailing Address - Country:US
Mailing Address - Phone:407-620-1924
Mailing Address - Fax:
Practice Address - Street 1:1317 EDGEWATER DR STE 1604
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-6350
Practice Address - Country:US
Practice Address - Phone:407-620-1924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor