Provider Demographics
NPI:1053012591
Name:LAZAR, SAMANTHA ANNITZA (RD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANNITZA
Last Name:LAZAR
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:ANNITZA
Other - Last Name:MCENHILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1435 W TALMAGE ST APT A113
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-1281
Mailing Address - Country:US
Mailing Address - Phone:916-661-1400
Mailing Address - Fax:
Practice Address - Street 1:1500 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-3099
Practice Address - Country:US
Practice Address - Phone:417-328-6752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023008696133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered