Basic Information
| Provider Information | |||||||||
| NPI: | 1528132636 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAMUEL | ||||||||
| FirstName: | TSEDAY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | ACNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 631 PROFESSIONAL DR | ||||||||
| Address2: | STE 360 | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300463367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709624895 | ||||||||
| FaxNumber: | 7709624792 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 TREE LN STE 190 | ||||||||
| Address2: | |||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300786766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707366300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 02/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN172768NP | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | RN172768 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 923160586A | 05 | GA | MEDICAID |