Provider Demographics
NPI:1821656224
Name:COLE, SAMANTHA JOLYN
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JOLYN
Last Name:COLE
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 1:150 IRVINE BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-8914
Mailing Address - Country:US
Mailing Address - Phone:307-351-1520
Mailing Address - Fax:
Practice Address - Street 1:150 IRVINE BRIDGE RD
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-8914
Practice Address - Country:US
Practice Address - Phone:307-351-1520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-31
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
20000423172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty