Provider Demographics
NPI:1063561876
Name:SAMAKE, WANDA SEXTON (DNP, PMHNP, FNP)
Entity type:Individual
Prefix:DR
First Name:WANDA
Middle Name:SEXTON
Last Name:SAMAKE
Suffix:
Gender:F
Credentials:DNP, PMHNP, FNP
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:CHARLENE
Other - Last Name:SEXTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP, PMHNP, FNP
Mailing Address - Street 1:PO BOX 25472
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29616-0472
Mailing Address - Country:US
Mailing Address - Phone:864-990-5664
Mailing Address - Fax:
Practice Address - Street 1:300 JOHN ST UNIT 5B
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29651-1463
Practice Address - Country:US
Practice Address - Phone:864-990-5664
Practice Address - Fax:864-990-5674
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN150441363LF0000X
SC2159363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q32051Medicare UPIN