=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164007381
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA MARIE BLACKWELL NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2021
-----------------------------------------------------
Last Update Date | 03/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1083 BOILING SPRINGS RD
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29303-2248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-583-8647
-----------------------------------------------------
Fax | 864-542-2227
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 743070
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30374-3070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-560-4304
-----------------------------------------------------
Fax | 864-560-4413
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 24729
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------