Provider Demographics
NPI:1720618960
Name:HANNA, SAMANTHA LAYNE (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LAYNE
Last Name:HANNA
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 SOUTHVIEW AVE APT 304
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-5094
Mailing Address - Country:US
Mailing Address - Phone:904-200-7646
Mailing Address - Fax:
Practice Address - Street 1:875 PERIMETER DRIVE COLLEGE OF EDUCATION 123
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83844-0001
Practice Address - Country:US
Practice Address - Phone:904-200-7646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID6612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer