Provider Demographics
NPI:1669019204
Name:KLOSS, SAMANTHA LYNN
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:LYNN
Last Name:KLOSS
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 1:428 N LOOMIS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-1930
Mailing Address - Country:US
Mailing Address - Phone:484-678-6719
Mailing Address - Fax:
Practice Address - Street 1:313 W DRAKE RD STE 210
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-2886
Practice Address - Country:US
Practice Address - Phone:970-472-0955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0002522171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist