Provider Demographics
NPI:1225785975
Name:GERRY, SAMANTHA LYNN (RD, LDN)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNN
Last Name:GERRY
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6830 W WINDING TRL UNIT 102
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-5216
Mailing Address - Country:US
Mailing Address - Phone:708-446-4355
Mailing Address - Fax:
Practice Address - Street 1:6830 W WINDING TRL UNIT 102
Practice Address - Street 2:
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-5216
Practice Address - Country:US
Practice Address - Phone:708-446-4355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-02
Last Update Date:2023-07-17
Deactivation Date:2023-06-14
Deactivation Code:
Reactivation Date:2023-07-17
Provider Licenses
StateLicense IDTaxonomies
IL164.008138133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered