Provider Demographics
NPI:1528132636
Name:SAMUEL, TSEDAY (ACNP-C)
Entity type:Individual
Prefix:MISS
First Name:TSEDAY
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:ACNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 PROFESSIONAL DR
Mailing Address - Street 2:STE 360
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3367
Mailing Address - Country:US
Mailing Address - Phone:770-962-4895
Mailing Address - Fax:770-962-4792
Practice Address - Street 1:1700 TREE LN STE 190
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6766
Practice Address - Country:US
Practice Address - Phone:770-736-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN172768363LA2100X
GARN172768NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA923160586AMedicaid
50BBJLLMedicare ID - Type Unspecified
GAQ46982Medicare UPIN