Provider Demographics
NPI:1619402831
Name:SANNER, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:SANNER
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 1:10315 GRAND RIVER RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-9594
Mailing Address - Country:US
Mailing Address - Phone:810-588-2324
Mailing Address - Fax:
Practice Address - Street 1:10315 GRAND RIVER RD
Practice Address - Street 2:SUITE 203
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-9594
Practice Address - Country:US
Practice Address - Phone:810-588-2324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist