Provider Demographics
NPI:1992199053
Name:TIENKEN, SAMANTHA (MA, ATC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:TIENKEN
Suffix:
Gender:F
Credentials:MA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S COLLEGE AVE
Mailing Address - Street 2:125 MORROW
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-2626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 S COLLEGE AVE
Practice Address - Street 2:125 MORROW
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-2626
Practice Address - Country:US
Practice Address - Phone:660-543-8868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-26
Last Update Date:2018-07-18
Deactivation Date:2018-01-25
Deactivation Code:
Reactivation Date:2018-07-18
Provider Licenses
StateLicense IDTaxonomies
MO20140304102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer