Provider Demographics
NPI:1407730898
Name:SURPRENANT, SAMANTHA (RD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:SURPRENANT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 FOUNDRY WAY APT 302
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-5885
Mailing Address - Country:US
Mailing Address - Phone:252-202-1678
Mailing Address - Fax:
Practice Address - Street 1:2611 FOUNDRY WAY APT 302
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-5885
Practice Address - Country:US
Practice Address - Phone:252-202-1678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-31
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA86377736133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered