Provider Demographics
NPI:1174298491
Name:VALLEJO, SAMANTHA (RDN)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:VALLEJO
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 1:3108 GULL AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1731
Mailing Address - Country:US
Mailing Address - Phone:631-294-2090
Mailing Address - Fax:
Practice Address - Street 1:3108 GULL AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-1731
Practice Address - Country:US
Practice Address - Phone:631-294-2090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY086073674133VN1201X
086073674133VN1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management