Healthcare Provider Details

I. General information

NPI: 1811938111
Provider Name (Legal Business Name): SAMANTHA STODDARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 04/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 EAGLES LANDING PKWY STE 280
STOCKBRIDGE GA
30281-5173
US

IV. Provider business mailing address

2727 PACES FERRY RD SE STE 1-100
ATLANTA GA
30339-6150
US

V. Phone/Fax

Practice location:
  • Phone: 770-507-5055
  • Fax:
Mailing address:
  • Phone: 470-271-3418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN102555
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: