Provider Demographics
NPI:1285044750
Name:ELLIS, SAMANTHA (MS, RD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:WALDEN
Mailing Address - State:NY
Mailing Address - Zip Code:12586-1240
Mailing Address - Country:US
Mailing Address - Phone:845-597-8128
Mailing Address - Fax:
Practice Address - Street 1:44 PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:WALDEN
Practice Address - State:NY
Practice Address - Zip Code:12586-1240
Practice Address - Country:US
Practice Address - Phone:845-597-8128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1033283133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered