Basic Information
| Provider Information | |||||||||
| NPI: | 1497368443 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | ATC, LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9857 BONEY FALLS H RD | ||||||||
| Address2: | |||||||||
| City: | CORNELL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498189528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063990233 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1970 S RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543044125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204304888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2020 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 2601002813 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.