Provider Demographics
NPI:1912470485
Name:POLLOCK, SAMANTHA POWELL (RN)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:POWELL
Last Name:POLLOCK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CRYSTAL CREEK LN
Mailing Address - Street 2:
Mailing Address - City:APPLING
Mailing Address - State:GA
Mailing Address - Zip Code:30802-3713
Mailing Address - Country:US
Mailing Address - Phone:706-399-0822
Mailing Address - Fax:
Practice Address - Street 1:3651 WHEELER RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6521
Practice Address - Country:US
Practice Address - Phone:706-651-3232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00000000000367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered