Provider Demographics
NPI:1619402831
Name:SANNER, SAMANTHA (MBA, RDN, LDN)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:SANNER
Suffix:
Gender:
Credentials:MBA, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-2935
Mailing Address - Country:US
Mailing Address - Phone:412-215-9428
Mailing Address - Fax:
Practice Address - Street 1:6 CENTRE CT
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:VA
Practice Address - Zip Code:22963-2329
Practice Address - Country:US
Practice Address - Phone:412-215-9428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-25
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND8516133V00000X
TN5274133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered