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General NPI Number Information
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NPI Number | 1720618960
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Entity Type | Individual
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Provider Name | SAMANTHA LAYNE HANNA MS, LAT, ATC
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Gender | Female
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Dates
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Enumeration Date | 01/15/2020
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Last Update Date | 01/15/2020
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Provider Practice Location Address
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Address Line | 875 PERIMETER DRIVE COLLEGE OF EDUCATION 123
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City | MOSCOW
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State | ID
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Zip | 83844-0001
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Country | US
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Telephone | 904-200-7646
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Fax |
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Provider Business Mailing Address
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Address Line | 251 SOUTHVIEW AVE APT 304
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City | MOSCOW
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State | ID
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Zip | 83843-5094
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Country | US
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Telephone | 904-200-7646
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 661
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License Number State | ID
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