Provider Demographics
NPI:1265222194
Name:BALOGUN, SAMAIYA (LPN)
Entity type:Individual
Prefix:
First Name:SAMAIYA
Middle Name:
Last Name:BALOGUN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 E PINE ST # 1245
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-4969
Mailing Address - Country:US
Mailing Address - Phone:863-852-6420
Mailing Address - Fax:
Practice Address - Street 1:3751 WHITEDOVE DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33812-4164
Practice Address - Country:US
Practice Address - Phone:863-852-6420
Practice Address - Fax:863-852-6420
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care