Provider Demographics
NPI:1497527634
Name:GOFFREDO, SAMANTHA MARIE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:GOFFREDO
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 1:121 CHARLES ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-2928
Mailing Address - Country:US
Mailing Address - Phone:203-577-7748
Mailing Address - Fax:
Practice Address - Street 1:121 CHARLES ST UNIT 2
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-2928
Practice Address - Country:US
Practice Address - Phone:203-577-7748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist