Provider Demographics
NPI:1275164774
Name:PRENTISS, SAMANTHA (RDN, LD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:PRENTISS
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:MRS
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:PRENTISS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, LD
Mailing Address - Street 1:3724 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6225
Mailing Address - Country:US
Mailing Address - Phone:512-692-7045
Mailing Address - Fax:
Practice Address - Street 1:828 MULBERRY DR
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-4701
Practice Address - Country:US
Practice Address - Phone:203-801-8030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-03
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT85130133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty