Provider Demographics
NPI:1164007381
Name:BLACKWELL, SAMANTHA MARIE (NP)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:MARIE
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:BOLT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:1083 BOILING SPRINGS RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-2248
Practice Address - Country:US
Practice Address - Phone:864-583-8647
Practice Address - Fax:864-542-2227
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24729363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP7493Medicaid
SCSCJ8335019OtherMEDICARE PIN