Provider Demographics
NPI:1275137432
Name:KRUTKA, SAMANTHA LILLIAN (RD, LD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LILLIAN
Last Name:KRUTKA
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3379 MORRISON AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220-1441
Mailing Address - Country:US
Mailing Address - Phone:513-833-3159
Mailing Address - Fax:
Practice Address - Street 1:3839 INDIAN RIPPLE RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45440-3468
Practice Address - Country:US
Practice Address - Phone:937-431-0455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.09199133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered