Healthcare Provider Details

I. General information

NPI: 1922831593
Provider Name (Legal Business Name): SAMANTHA GRAHAM OTIS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 08/20/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1009 GLENHAVEN DR
EVANS GA
30809-0420
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-2273
  • Fax:
Mailing address:
  • Phone: 706-339-1570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN260847
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: