Provider Demographics
NPI:1346021995
Name:O'DONNELL, SAMANTHA RAE
Entity Type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:RAE
Last Name:O'DONNELL
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 1:517 TIPTON AVE NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-1853
Mailing Address - Country:US
Mailing Address - Phone:763-910-5648
Mailing Address - Fax:
Practice Address - Street 1:710 E RIVER RD
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-2828
Practice Address - Country:US
Practice Address - Phone:763-421-2807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-10
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist