Provider Demographics
NPI:1619638855
Name:SIDDIQI, SAMIYAH (RD)
Entity Type:Individual
Prefix:
First Name:SAMIYAH
Middle Name:
Last Name:SIDDIQI
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 1:4146 PLACID LAKE CT
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-3521
Mailing Address - Country:US
Mailing Address - Phone:848-459-3100
Mailing Address - Fax:
Practice Address - Street 1:4146 PLACID LAKE CT
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-3521
Practice Address - Country:US
Practice Address - Phone:848-459-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-09
Last Update Date:2022-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA86175046133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered