Provider Demographics
NPI:1669169066
Name:HORNBUCKLE, SAMANTHA ANN
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANN
Last Name:HORNBUCKLE
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 1:599 FARMINGTON AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-2381
Mailing Address - Country:US
Mailing Address - Phone:860-837-9676
Mailing Address - Fax:
Practice Address - Street 1:599 FARMINGTON AVE FL 2
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-2381
Practice Address - Country:US
Practice Address - Phone:860-837-9676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001610156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician