=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386594836
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PRINCESS SAMARRA WISE APRN, FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2026
-----------------------------------------------------
Last Update Date | 02/02/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2730 PEACHTREE INDUSTRIAL BLVD STE 105
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30097-8627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-600-2458
-----------------------------------------------------
Fax | 770-600-2459
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2730 PEACHTREE INDUSTRIAL BLVD STE 105
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30097-8627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-600-2458
-----------------------------------------------------
Fax | 770-600-2459
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A188755
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 4704436467
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | APRN-NP316052
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------