Provider Demographics
NPI:1194323345
Name:SAMELSON, DANIELLE SARA (RD)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:SARA
Last Name:SAMELSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 N POPLAR ST APT 10
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-1656
Mailing Address - Country:US
Mailing Address - Phone:407-252-5258
Mailing Address - Fax:
Practice Address - Street 1:229 N POPLAR ST APT 10
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-1656
Practice Address - Country:US
Practice Address - Phone:407-252-5258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-10
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86152572133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered