Healthcare Provider Details

I. General information

NPI: 1366261307
Provider Name (Legal Business Name): SAMANTHA RENSON ATC, MAT, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 10/07/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 MAIN ST
KEENE NH
03435-0001
US

IV. Provider business mailing address

23 ADAMS STREET APT 2
KEENE NH
03431
US

V. Phone/Fax

Practice location:
  • Phone: 800-572-1909
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1588
License Number StateNH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: