Provider Demographics
NPI:1255736658
Name:GOSS, SAMANTHA (RHD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GOSS
Suffix:
Gender:F
Credentials:RHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9059 NW 35TH PL
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-6437
Mailing Address - Country:US
Mailing Address - Phone:754-368-0895
Mailing Address - Fax:
Practice Address - Street 1:9059 NW 35TH PL
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-6437
Practice Address - Country:US
Practice Address - Phone:754-368-0895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND5011133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist