Provider Demographics
NPI:1780151555
Name:KOCIEMBA, SAMANTHA LEE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEE
Last Name:KOCIEMBA
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 1:1755 17TH AVE E
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-3372
Mailing Address - Country:US
Mailing Address - Phone:952-445-5250
Mailing Address - Fax:952-445-5350
Practice Address - Street 1:1755 17TH AVE E
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-3372
Practice Address - Country:US
Practice Address - Phone:952-445-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1356513592OtherMASSAGE