Provider Demographics
NPI:1902149750
Name:ELLEFSON, SAMANTHA (RD LD CSP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:ELLEFSON
Suffix:
Gender:F
Credentials:RD LD CSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:MAIL CODE: UHS 18
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-418-5257
Mailing Address - Fax:503-418-5317
Practice Address - Street 1:3181 S.W. SAM JACKSON PARK RD
Practice Address - Street 2:MAIL CODE: UHS 18
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3098
Practice Address - Country:US
Practice Address - Phone:503-418-5257
Practice Address - Fax:503-418-5317
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-30
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003133133V00000X
ORLD-D-10159207133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered