Provider Demographics
NPI:1437660974
Name:WANGNER, SAMANTHA H (MS, LAT, ATC, PES)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:H
Last Name:WANGNER
Suffix:
Gender:F
Credentials:MS, LAT, ATC, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1554 TEAL WAY
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3731
Mailing Address - Country:US
Mailing Address - Phone:571-244-3547
Mailing Address - Fax:
Practice Address - Street 1:14605 POTOMAC BRANCH DR STE 300
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3337
Practice Address - Country:US
Practice Address - Phone:703-490-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260032422255A2300X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer