Provider Demographics
NPI:1326737388
Name:RONK, SAMANTHA GAYLORD (MBA, RD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:GAYLORD
Last Name:RONK
Suffix:
Gender:F
Credentials:MBA, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8513 OAKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-2195
Mailing Address - Country:US
Mailing Address - Phone:804-514-5222
Mailing Address - Fax:
Practice Address - Street 1:8513 OAKVIEW DR
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-2195
Practice Address - Country:US
Practice Address - Phone:804-514-5222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA86021221133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered