Provider Demographics
NPI:1104000298
Name:SAMUEL-WORSHAM, RENNY (MS,RD,LD)
Entity Type:Individual
Prefix:MRS
First Name:RENNY
Middle Name:
Last Name:SAMUEL-WORSHAM
Suffix:
Gender:F
Credentials:MS,RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 S INWOOD HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78248-1684
Mailing Address - Country:US
Mailing Address - Phone:210-408-7223
Mailing Address - Fax:
Practice Address - Street 1:4204 GARDENDALE ST
Practice Address - Street 2:STE 106
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3138
Practice Address - Country:US
Practice Address - Phone:210-325-0147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-25
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT01379133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal