Provider Demographics
NPI:1750948394
Name:METKO, SAMANTHA A (RDN, IBCLC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:A
Last Name:METKO
Suffix:
Gender:F
Credentials:RDN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N3075 BEAN CITY RD
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-8912
Mailing Address - Country:US
Mailing Address - Phone:920-540-0094
Mailing Address - Fax:
Practice Address - Street 1:N3075 BEAN CITY RD
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-8912
Practice Address - Country:US
Practice Address - Phone:920-540-0094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-20
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-22761174N00000X
WI661-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI661-29OtherSTATE OF WISCONSIN: DEPARTMENT OF SAFETY PROFESSIONAL SERVICES
L-22761OtherIBCLC