Basic Information
| Provider Information | |||||||||
| NPI: | 1003144460 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERT | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | NICHOLE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LPTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 GLEN ECHO DR | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235054117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573147666 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 576 JEFFERSON AVE | ||||||||
| Address2: | MCDONALD ARMY HEALTH CENTER | ||||||||
| City: | FORT EUSTIS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236045548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573147616 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2009 | ||||||||
| LastUpdateDate: | 11/24/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2306602749 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.