Provider Demographics
NPI:1497365720
Name:BROGHAMMER, SAMANTHA ANN (RD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANN
Last Name:BROGHAMMER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344A N 68TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3931
Mailing Address - Country:US
Mailing Address - Phone:920-946-2855
Mailing Address - Fax:
Practice Address - Street 1:4600 W SCHROEDER DR
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53223-6458
Practice Address - Country:US
Practice Address - Phone:414-865-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-02
Last Update Date:2020-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86095627133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered