Healthcare Provider Details

I. General information

NPI: 1568066330
Provider Name (Legal Business Name): SAMANTHA KOECHNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA WALDNER

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 MCLAIN ST
NEWPORT AR
72112-3662
US

IV. Provider business mailing address

2809 FOREST HOME RD
JONESBORO AR
72401-5320
US

V. Phone/Fax

Practice location:
  • Phone: 870-495-1990
  • Fax:
Mailing address:
  • Phone: 866-972-1268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: