Provider Demographics
NPI:1972604635
Name:SMITH, SAMANTHA JEAN (RD)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:JEAN
Last Name:SMITH
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:HWY 160 M.P. 394.3
Mailing Address - Street 2:PO BOX 3247
Mailing Address - City:KAYENTA
Mailing Address - State:AZ
Mailing Address - Zip Code:86033-3247
Mailing Address - Country:US
Mailing Address - Phone:928-697-4210
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 368
Practice Address - Street 2:
Practice Address - City:KAYENTA
Practice Address - State:AZ
Practice Address - Zip Code:86033-0368
Practice Address - Country:US
Practice Address - Phone:928-697-4000
Practice Address - Fax:928-697-4145
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ00945082133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered