Provider Demographics
NPI:1639402654
Name:VILLA, SAMANTHA REBEKAH (MS, ATC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:REBEKAH
Last Name:VILLA
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3266 NUTMEG STREET
Mailing Address - Street 2:ATHLETIC TRAINING FACILITY
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104
Mailing Address - Country:US
Mailing Address - Phone:619-282-2184
Mailing Address - Fax:619-282-1203
Practice Address - Street 1:3117 30TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-4505
Practice Address - Country:US
Practice Address - Phone:619-417-6451
Practice Address - Fax:478-301-2039
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-09
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAAT0016822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer