Provider Demographics
NPI:1760355937
Name:GREENE, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GREENE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2831 CONSERVANCY LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-8172
Mailing Address - Country:US
Mailing Address - Phone:910-684-0132
Mailing Address - Fax:
Practice Address - Street 1:2831 CONSERVANCY LN
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-8172
Practice Address - Country:US
Practice Address - Phone:910-684-0132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-24
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1649133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered