Healthcare Provider Details

I. General information

NPI: 1063802163
Provider Name (Legal Business Name): SAMANTHA QUISENBERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2015
Last Update Date: 01/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 SANDPOINTE AVE SUITE 130
SANTA ANA CA
92707-5778
US

IV. Provider business mailing address

120 CALLE AMISTAD UNIT 5104
SAN CLEMENTE CA
92673-6917
US

V. Phone/Fax

Practice location:
  • Phone: 714-557-9292
  • Fax:
Mailing address:
  • Phone: 949-945-4788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT10655
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: