Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 5501017213 | MI |
NPI | 1003282187 |
---|---|
Provider Name | Samantha Michelle Flietstra |
First Address | Walker, MI 49534-1249 |
Second Address | Grand Rapids, MI 49504-3829 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2015 |
Last Update Date | 12/08/2015 |