Provider Demographics
NPI:1285005017
Name:OLDMAN, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:OLDMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 ALLEN ROAD
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 SAYBROOK ROAD
Practice Address - Street 2:110
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457
Practice Address - Country:US
Practice Address - Phone:860-347-9167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1369133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered