Basic Information
| Provider Information | |||||||||
| NPI: | 1871122036 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAMUEL | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | LEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 N IRBY ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295012808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436679414 | ||||||||
| FaxNumber: | 8436671362 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 E MARKET ST | ||||||||
| Address2: | |||||||||
| City: | TIMMONSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291611812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433463730 | ||||||||
| FaxNumber: | 8433467689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2020 | ||||||||
| LastUpdateDate: | 04/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 23819 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.