Healthcare Provider Details

I. General information

NPI: 1114426806
Provider Name (Legal Business Name): SAMANTHA MARIE HYDES APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 BRECKINRIDGE BLVD STE 200
DULUTH GA
30096-4959
US

IV. Provider business mailing address

1160 BRIARCLIFF RD NE APT 1
ATLANTA GA
30306-2661
US

V. Phone/Fax

Practice location:
  • Phone: 678-990-6422
  • Fax:
Mailing address:
  • Phone: 954-562-7332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN262052
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN262052
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: