Provider Demographics
NPI:1053653071
Name:FERNEBOK, SAMANTHA R
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:R
Last Name:FERNEBOK
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 1:5015 CLINTON ST
Mailing Address - Street 2:APT 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-1748
Mailing Address - Country:US
Mailing Address - Phone:240-372-1531
Mailing Address - Fax:
Practice Address - Street 1:5015 CLINTON ST
Practice Address - Street 2:APT 301
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-1748
Practice Address - Country:US
Practice Address - Phone:240-372-1531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-18
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39407225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist