Healthcare Provider Details

I. General information

NPI: 1265056386
Provider Name (Legal Business Name): SAMANTHA ANNE MOLONY LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 A O JONES BLVD
FORT MILL SC
29715-1625
US

IV. Provider business mailing address

171 CLEGGAN RD APT 305
ROCK HILL SC
29730-5879
US

V. Phone/Fax

Practice location:
  • Phone: 803-835-0024
  • Fax:
Mailing address:
  • Phone: 843-478-1151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number2166
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberLAT-3146
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: