Provider Demographics
NPI:1699370064
Name:FISHER, SAMANTHA ANN (RD, LD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANN
Last Name:FISHER
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:ANN
Other - Last Name:BURATTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:PO BOX 1633
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-0870
Mailing Address - Country:US
Mailing Address - Phone:208-290-2849
Mailing Address - Fax:
Practice Address - Street 1:30544 HIGHWAY 200 STE 103
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-5005
Practice Address - Country:US
Practice Address - Phone:208-946-5110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1162133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered