Provider Demographics
NPI:1033826052
Name:RUNKEL, SAMANTHA MICHELLE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MICHELLE
Last Name:RUNKEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SHINNECOCK AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-6716
Mailing Address - Country:US
Mailing Address - Phone:516-462-4353
Mailing Address - Fax:
Practice Address - Street 1:7 SHINNECOCK AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-6716
Practice Address - Country:US
Practice Address - Phone:516-462-4353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0491172251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics