Healthcare Provider Details

I. General information

NPI: 1962271254
Provider Name (Legal Business Name): SAMISHA TANKEYIA ROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2023
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6885 CLIFFDALE RD STE 202
FAYETTEVILLE NC
28314-2834
US

IV. Provider business mailing address

1229 PEE DEE CHURCH RD
DILLON SC
29536-7744
US

V. Phone/Fax

Practice location:
  • Phone: 910-339-0400
  • Fax:
Mailing address:
  • Phone: 843-627-3121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP024139
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number390200000X
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: