Provider Demographics
NPI:1073350351
Name:RUSSOMANO, SAMANTHA (RDN)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:
Last Name:RUSSOMANO
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 S PARK ST APT 302
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2753
Mailing Address - Country:US
Mailing Address - Phone:862-703-9379
Mailing Address - Fax:
Practice Address - Street 1:51 S PARK ST APT 302
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2753
Practice Address - Country:US
Practice Address - Phone:862-703-9379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ86378698133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered