Healthcare Provider Details

I. General information

NPI: 1740915800
Provider Name (Legal Business Name): SAMANTHA LEIGH WHITE MCN, RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2022
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 E OAK ST
SUNDANCE WY
82729-5172
US

IV. Provider business mailing address

PO BOX 1134
SUNDANCE WY
82729-1134
US

V. Phone/Fax

Practice location:
  • Phone: 307-283-3501
  • Fax: 307-283-3506
Mailing address:
  • Phone: 720-648-2211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number431
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86172305
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: