Healthcare Provider Details

I. General information

NPI: 1689117061
Provider Name (Legal Business Name): SAMANTHA YEKEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA YEKEL STUDENT

II. Dates (important events)

Enumeration Date: 12/02/2016
Last Update Date: 12/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 NORTH RD
EAST GRANBY CT
06026-9588
US

IV. Provider business mailing address

41 NORTH RD
EAST GRANBY CT
06026-9588
US

V. Phone/Fax

Practice location:
  • Phone: 860-948-8648
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: