Healthcare Provider Details

I. General information

NPI: 1225600745
Provider Name (Legal Business Name): SAMUEL ABDIAS LOUISSAINT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 12/29/2024
Certification Date: 12/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 PAVILION CT STE A
MCDONOUGH GA
30253-6790
US

IV. Provider business mailing address

403 PAULOWNIA CIR
MCDONOUGH GA
30253-3092
US

V. Phone/Fax

Practice location:
  • Phone: 770-321-1773
  • Fax:
Mailing address:
  • Phone: 857-236-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN311141
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2324549
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: