Basic Information
Provider Information | |||||||||
NPI: | 1467858993 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARASEK | ||||||||
FirstName: | SAMANTHA | ||||||||
MiddleName: | N | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | R.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PATTY | ||||||||
OtherFirstName: | SAMANTHA | ||||||||
OtherMiddleName: | N | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | R.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2917 | ||||||||
Address2: |   | ||||||||
City: | PIKEVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 415022917 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6062181000 | ||||||||
FaxNumber: | 6064331867 | ||||||||
Practice Location | |||||||||
Address1: | 1098 S MAYO TRL | ||||||||
Address2: | SUITE 101 | ||||||||
City: | PIKEVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 415011546 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6062181000 | ||||||||
FaxNumber: | 6064331867 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/11/2014 | ||||||||
LastUpdateDate: | 07/29/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DT83315 | TX | N |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   | 133V00000X | BDNDTN00221252 | KY | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
No ID Information.