Provider Demographics
NPI:1215981253
Name:SAMPSON, CORLISS S (MS, RD)
Entity type:Individual
Prefix:MS
First Name:CORLISS
Middle Name:S
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8625 VAN WYCK EXPY
Mailing Address - Street 2:APT L30
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-2931
Mailing Address - Country:US
Mailing Address - Phone:718-526-1000
Mailing Address - Fax:
Practice Address - Street 1:8625 VAN WYCK EXPY
Practice Address - Street 2:APT L30
Practice Address - City:BRIARWOOD
Practice Address - State:NY
Practice Address - Zip Code:11435-2931
Practice Address - Country:US
Practice Address - Phone:718-526-1000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered