Provider Demographics
NPI:1972072924
Name:HOLLOCK, SAMANTHA LYNN (RDN, LDN)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNN
Last Name:HOLLOCK
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:LYNN
Other - Last Name:CANTWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 E MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18711-0027
Mailing Address - Country:US
Mailing Address - Phone:570-714-6716
Mailing Address - Fax:
Practice Address - Street 1:1000 E MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0001
Practice Address - Country:US
Practice Address - Phone:570-714-6716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-20
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN006235133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered