Provider Demographics
NPI:1821344557
Name:SAMUEL, NELLIE IDARA (MSN, APRN,PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:NELLIE
Middle Name:IDARA
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:MSN, APRN,PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 POST DRIVE
Mailing Address - Street 2:P O BOX 6250
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93912
Mailing Address - Country:US
Mailing Address - Phone:865-765-8225
Mailing Address - Fax:
Practice Address - Street 1:2400 NORTHSIDE XING
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2252
Practice Address - Country:US
Practice Address - Phone:865-765-8225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN225022163WP0807X, 163WP0808X, 163WP0809X, 363LP0808X
AZAP10318363LP0808X
CA95014791363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult