Provider Demographics
NPI:1720538473
Name:ANDERSON, SAMANTHA JOSEPHINE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JOSEPHINE
Last Name:ANDERSON
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 1:17 5TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:OSSEO
Mailing Address - State:MN
Mailing Address - Zip Code:55369-1305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17 5TH AVE NE
Practice Address - Street 2:
Practice Address - City:OSSEO
Practice Address - State:MN
Practice Address - Zip Code:55369-1305
Practice Address - Country:US
Practice Address - Phone:612-799-9621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer