Provider Demographics
NPI:1417612151
Name:ROMAN-HOLBA, SAMARA LILY (MS, EDM, RD, LD)
Entity Type:Individual
Prefix:
First Name:SAMARA
Middle Name:LILY
Last Name:ROMAN-HOLBA
Suffix:
Gender:F
Credentials:MS, EDM, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5036 NE 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-5078
Mailing Address - Country:US
Mailing Address - Phone:310-906-8950
Mailing Address - Fax:
Practice Address - Street 1:8414 SW BARBUR BLVD STE 203
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-4018
Practice Address - Country:US
Practice Address - Phone:310-906-8950
Practice Address - Fax:855-702-2328
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10217666133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered