Provider Demographics
NPI:1124614631
Name:FREDERICK, SAMANTHA F (NP-C)
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:F
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 SAVOY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1071
Mailing Address - Country:US
Mailing Address - Phone:678-288-9555
Mailing Address - Fax:770-479-1870
Practice Address - Street 1:228 RIVERSTONE DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5256
Practice Address - Country:US
Practice Address - Phone:770-479-1870
Practice Address - Fax:770-479-9705
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN203567363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG24488AOtherMEDICARE PTAN
GA003245264AMedicaid
GA003245264BMedicaid