Provider Demographics
NPI:1376415513
Name:SELSOR, SAMANTHA GRACE (MS, RDN, LD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:GRACE
Last Name:SELSOR
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 W RIVERSIDE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-4658
Mailing Address - Country:US
Mailing Address - Phone:417-612-4982
Mailing Address - Fax:
Practice Address - Street 1:731 W RIVERSIDE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-4658
Practice Address - Country:US
Practice Address - Phone:417-612-4982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-18
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025030620133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered