Basic Information
| Provider Information | |||||||||
| NPI: | 1730562810 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLARD | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APRN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3239 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295023239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437777120 | ||||||||
| FaxNumber: | 8437777102 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 S GEORGETOWN HWY | ||||||||
| Address2: | |||||||||
| City: | JOHNSONVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295558083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433802000 | ||||||||
| FaxNumber: | 8433802014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2015 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 19580 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | NP3342 | 05 | SC | MEDICAID |