Provider Demographics
NPI:1154604015
Name:ROBERTSON, SAMARA (LPN)
Entity type:Individual
Prefix:
First Name:SAMARA
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 STATION CLUB DR.
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1227
Mailing Address - Country:US
Mailing Address - Phone:678-540-2857
Mailing Address - Fax:
Practice Address - Street 1:2107 STATION CLUB DR SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7517
Practice Address - Country:US
Practice Address - Phone:678-540-2857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN089484164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse