Healthcare Provider Details

I. General information

NPI: 1548916620
Provider Name (Legal Business Name): SAMANTHA MARIE PHIFER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2022
Last Update Date: 12/10/2023
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 ROTUNDA ST APT 303
LYNCHBURG VA
24502-2076
US

IV. Provider business mailing address

103 CAPITAL ST UNIT 208
LYNCHBURG VA
24502-5160
US

V. Phone/Fax

Practice location:
  • Phone: 201-577-1147
  • Fax:
Mailing address:
  • Phone: 201-577-1147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: