Provider Demographics
NPI:1336716547
Name:BAILEY, SAMANTHA (RDN)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BAILEY
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 1:66 BIRCHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:ME
Mailing Address - Zip Code:04039-7761
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:805 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2647
Practice Address - Country:US
Practice Address - Phone:207-772-6279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
MEDI1581133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist