Provider Demographics
NPI:1740915800
Name:WHITE, SAMANTHA LEIGH (MCN, RDN)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEIGH
Last Name:WHITE
Suffix:
Gender:F
Credentials:MCN, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1134
Mailing Address - Street 2:
Mailing Address - City:SUNDANCE
Mailing Address - State:WY
Mailing Address - Zip Code:82729-1134
Mailing Address - Country:US
Mailing Address - Phone:720-648-2211
Mailing Address - Fax:
Practice Address - Street 1:713 E OAK ST
Practice Address - Street 2:
Practice Address - City:SUNDANCE
Practice Address - State:WY
Practice Address - Zip Code:82729-5172
Practice Address - Country:US
Practice Address - Phone:307-283-3501
Practice Address - Fax:307-283-3506
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-21
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY431133V00000X
CO86172305133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered