Provider Demographics
NPI:1780201186
Name:PREVITE, SAMANTHA ELISE (RD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ELISE
Last Name:PREVITE
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 1:174 PINEWOODS ST FL 32081
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-0118
Mailing Address - Country:US
Mailing Address - Phone:724-816-5571
Mailing Address - Fax:
Practice Address - Street 1:174 PINEWOODS ST
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-0118
Practice Address - Country:US
Practice Address - Phone:724-816-5571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND7815133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered