Healthcare Provider Details

I. General information

NPI: 1912607722
Provider Name (Legal Business Name): SAMANTHA THOMS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2023
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 LEARNING WAY
TALLAHASSEE FL
32306-0001
US

IV. Provider business mailing address

960 LEARNING WAY
TALLAHASSEE FL
32306-0001
US

V. Phone/Fax

Practice location:
  • Phone: 850-672-2571
  • Fax: 850-644-4251
Mailing address:
  • Phone: 850-672-2571
  • Fax: 850-644-4251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND11586
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: