Healthcare Provider Details

I. General information

NPI: 1912470485
Provider Name (Legal Business Name): SAMANTHA POWELL POLLOCK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2019
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3651 WHEELER RD
AUGUSTA GA
30909-6521
US

IV. Provider business mailing address

110 CRYSTAL CREEK LN
APPLING GA
30802-3713
US

V. Phone/Fax

Practice location:
  • Phone: 706-651-3232
  • Fax:
Mailing address:
  • Phone: 706-399-0822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number00000000000
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: