Healthcare Provider Details

I. General information

NPI: 1164007381
Provider Name (Legal Business Name): SAMANTHA MARIE BLACKWELL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA BOLT NP

II. Dates (important events)

Enumeration Date: 03/10/2021
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1083 BOILING SPRINGS RD
SPARTANBURG SC
29303-2248
US

IV. Provider business mailing address

PO BOX 743070
ATLANTA GA
30374-3070
US

V. Phone/Fax

Practice location:
  • Phone: 864-583-8647
  • Fax: 864-542-2227
Mailing address:
  • Phone: 864-560-4304
  • Fax: 864-560-4413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number24729
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: