Provider Demographics
NPI:1457698870
Name:WISE, SAMANTHA WAMBLES (LPTA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:WAMBLES
Last Name:WISE
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 HICKMAN AVE E
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:AL
Mailing Address - Zip Code:36453-3414
Mailing Address - Country:US
Mailing Address - Phone:334-897-8265
Mailing Address - Fax:
Practice Address - Street 1:303 N HURSTBOURNE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5158
Practice Address - Country:US
Practice Address - Phone:502-412-5847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTA5120225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant