Healthcare Provider Details

I. General information

NPI: 1457943078
Provider Name (Legal Business Name): SAMANTHA GREEN LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2021
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 TUNNEL HILL VARNELL RD NW
DALTON GA
30720-6301
US

IV. Provider business mailing address

1625 TUNNEL HILL VARNELL RD NW
DALTON GA
30720-6301
US

V. Phone/Fax

Practice location:
  • Phone: 706-581-2315
  • Fax:
Mailing address:
  • Phone: 706-581-2315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN094650
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: