Provider Demographics
NPI:1457943078
Name:GREEN, SAMANTHA (LPN)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 TUNNEL HILL VARNELL RD NW
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-6301
Mailing Address - Country:US
Mailing Address - Phone:706-581-2315
Mailing Address - Fax:
Practice Address - Street 1:1625 TUNNEL HILL VARNELL RD NW
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-6301
Practice Address - Country:US
Practice Address - Phone:706-581-2315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN094650164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse