Provider Demographics
NPI:1467097352
Name:DREW-TACKETT, SAMANTHA ELOISE (NP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ELOISE
Last Name:DREW-TACKETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4310 HARD SCRABBLE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-9423
Mailing Address - Country:US
Mailing Address - Phone:803-865-6682
Mailing Address - Fax:
Practice Address - Street 1:4310 HARD SCRABBLE RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-9423
Practice Address - Country:US
Practice Address - Phone:803-865-6682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-14
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23428363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1467097352Medicaid