Basic Information
| Provider Information | |||||||||
| NPI: | 1275164774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRENTISS | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RDN, LD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PRENTISS | ||||||||
| OtherFirstName: | SAMANTHA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RDN, LD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 700 E PARK BLVD STE 206 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750745472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724229180 | ||||||||
| FaxNumber: | 8888212292 | ||||||||
| Practice Location | |||||||||
| Address1: | 3004 50TH ST STE A | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794134129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724229180 | ||||||||
| FaxNumber: | 8888212292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2020 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DT85130 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.