Provider Demographics
NPI:1417697186
Name:SAMUEL, JANIE MAE
Entity Type:Individual
Prefix:
First Name:JANIE
Middle Name:MAE
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7177 SWEET GUM CT
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-2993
Mailing Address - Country:US
Mailing Address - Phone:770-572-9842
Mailing Address - Fax:
Practice Address - Street 1:7177 SWEET GUM CT
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-2993
Practice Address - Country:US
Practice Address - Phone:770-572-9842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA22046011347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle