Provider Demographics
NPI:1205349230
Name:KUSPA, SAMANTHA FAYE (RDN, CD, LD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:FAYE
Last Name:KUSPA
Suffix:
Gender:F
Credentials:RDN, CD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 ELM GROVE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2528
Mailing Address - Country:US
Mailing Address - Phone:262-352-6050
Mailing Address - Fax:
Practice Address - Street 1:890 ELM GROVE RD STE 100
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2528
Practice Address - Country:US
Practice Address - Phone:262-352-6050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86063505133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered