Healthcare Provider Details

I. General information

NPI: 1386594836
Provider Name (Legal Business Name): PRINCESS SAMARRA WISE APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2026
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 PEACHTREE INDUSTRIAL BLVD STE 105
DULUTH GA
30097-8627
US

IV. Provider business mailing address

2730 PEACHTREE INDUSTRIAL BLVD STE 105
DULUTH GA
30097-8627
US

V. Phone/Fax

Practice location:
  • Phone: 770-600-2458
  • Fax: 770-600-2459
Mailing address:
  • Phone: 770-600-2458
  • Fax: 770-600-2459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704436467
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP316052
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11045465
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number16765
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA188755
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: