Provider Demographics
NPI:1306722657
Name:SMITH, SAMANTHA MARIE (RDN)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-3150
Mailing Address - Country:US
Mailing Address - Phone:516-510-4743
Mailing Address - Fax:
Practice Address - Street 1:54 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-3150
Practice Address - Country:US
Practice Address - Phone:516-510-4743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-13
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012801-01133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered