MEDICARE: PRINCESS SAMARRA WISE APRN, FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	4704436467	MI
2	363LF0000X	Family Nurse Practitioner	APRN-NP316052	GA
3	363LF0000X	Family Nurse Practitioner	APRN11045465	FL
4	363LF0000X	Family Nurse Practitioner	16765	CT
5	363LF0000X	Family Nurse Practitioner	A188755	IA

General Provider Information

NPI Number	:	1386594836
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRINCESS SAMARRA WISE APRN, FNP-BC

Provider Business Mailing Address
First Line	:	2730 PEACHTREE INDUSTRIAL BLVD STE 105
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30097-8627
Country	:	US
Telephone Number	:	770-600-2458
Fax Number	:	770-600-2459

Provider Business Practice Location Address
First Line	:	2730 PEACHTREE INDUSTRIAL BLVD STE 105
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30097-8627
Country	:	US
Telephone Number	:	770-600-2458
Fax Number	:	770-600-2459

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2026
Last Update Date	:	03/27/2026

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