MEDICARE: SAMANTHA WREN ZICKEFOOSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	12131266	NE

General Provider Information

NPI Number	:	1336518984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA WREN ZICKEFOOSE

Provider Business Mailing Address
First Line	:	3822 CHICAGO ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68131-2319
Country	:	US
Telephone Number	:	402-612-9468
Fax Number	:

Provider Business Practice Location Address
First Line	:	3822 CHICAGO ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68131-2319
Country	:	US
Telephone Number	:	402-612-9468
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2015
Last Update Date	:	09/24/2015

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