Provider Demographics
NPI:1710718200
Name:NIVISON, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:NIVISON
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 1:5525 1ST AVE E APT 203
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-6098
Mailing Address - Country:US
Mailing Address - Phone:407-967-0660
Mailing Address - Fax:
Practice Address - Street 1:104 53RD AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-4702
Practice Address - Country:US
Practice Address - Phone:941-925-2700
Practice Address - Fax:941-925-7744
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2025-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT42053225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist