Basic Information
| Provider Information | |||||||||
| NPI: | 1225617301 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRYSIAK | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | JADE | ||||||||
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| Credential: | RDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 605 MEDINA DR | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND VILLAGE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750777214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052692181 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9040 JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539682252 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2021 | ||||||||
| LastUpdateDate: | 04/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.