Provider Demographics
NPI:1639774458
Name:BOEHNLEIN, SAMANTHA (DAC, LAC, CHC)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:
Last Name:BOEHNLEIN
Suffix:
Gender:F
Credentials:DAC, LAC, CHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W545 APPLE LN
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:WI
Mailing Address - Zip Code:53079-1485
Mailing Address - Country:US
Mailing Address - Phone:312-684-0332
Mailing Address - Fax:
Practice Address - Street 1:N7640 COUNTY ROAD WH
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-7835
Practice Address - Country:US
Practice Address - Phone:312-684-0332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1005-55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist