Healthcare Provider Details

I. General information

NPI: 1932850427
Provider Name (Legal Business Name): SAMANTHA ROSEBERRY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SAMANTHA YEARWOOD

II. Dates (important events)

Enumeration Date: 01/16/2022
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 ERIN DR
MEMPHIS TN
38177-0617
US

IV. Provider business mailing address

521 ERIN DR
MEMPHIS TN
38177-0617
US

V. Phone/Fax

Practice location:
  • Phone: 901-491-8646
  • Fax:
Mailing address:
  • Phone: 901-491-8646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2956
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: