Provider Demographics
NPI:1942754031
Name:ABBOTT, SAMARA (RD)
Entity Type:Individual
Prefix:
First Name:SAMARA
Middle Name:
Last Name:ABBOTT
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 1:2820 SELWYN AVE STE 745
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2765
Mailing Address - Country:US
Mailing Address - Phone:980-349-7763
Mailing Address - Fax:
Practice Address - Street 1:2820 SELWYN AVE STE 745
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-2765
Practice Address - Country:US
Practice Address - Phone:980-349-7763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-07
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004384133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered