Provider Demographics
NPI:1881160802
Name:LUSCZAKOSKI, SAMANTHA (APRN)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:LUSCZAKOSKI
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 S PINE ISLAND RD STE 800
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3923
Mailing Address - Country:US
Mailing Address - Phone:561-967-5761
Mailing Address - Fax:561-967-5762
Practice Address - Street 1:4075 S STATE ROAD 7 STE H1
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33449-8152
Practice Address - Country:US
Practice Address - Phone:561-967-5761
Practice Address - Fax:561-967-5762
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704308612363LP0200X
FLAPRN11003396363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104457700Medicaid