Provider Demographics
NPI:1003191297
Name:MOORE, SAMANTHA ELAINE (RD, CD, CDCES)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ELAINE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RD, CD, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5703
Mailing Address - Country:US
Mailing Address - Phone:715-389-7464
Mailing Address - Fax:
Practice Address - Street 1:1000 N OAK AVE
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-5703
Practice Address - Country:US
Practice Address - Phone:715-389-7464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1059416133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered