Provider Demographics
NPI:1477290781
Name:COLBOURNE, SAMANTHA (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:COLBOURNE
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6530 SENATOR DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-6001
Mailing Address - Country:US
Mailing Address - Phone:910-988-8753
Mailing Address - Fax:
Practice Address - Street 1:1682 LONGSTREET RD BLDG A
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-8480
Practice Address - Country:US
Practice Address - Phone:910-396-4789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
NCLAT-28322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer