Healthcare Provider Details

I. General information

NPI: 1205617859
Provider Name (Legal Business Name): SAMANTHA HAWKINSON DODD MS, ACSM-CEP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2023
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 S ONEIDA ST
APPLETON WI
54915-1305
US

IV. Provider business mailing address

111 MAIN AVE APT 103
KAUKAUNA WI
54130-2436
US

V. Phone/Fax

Practice location:
  • Phone: 920-738-2558
  • Fax:
Mailing address:
  • Phone: 920-475-4201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: