Provider Demographics
NPI:1093146128
Name:ANSELMO, ANTOINETTA V (RD)
Entity Type:Individual
Prefix:MS
First Name:ANTOINETTA
Middle Name:V
Last Name:ANSELMO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 N ALMA SCHOOL RD UNIT 5
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-5474
Mailing Address - Country:US
Mailing Address - Phone:602-803-4522
Mailing Address - Fax:480-621-8109
Practice Address - Street 1:544 N ALMA SCHOOL RD UNIT 5
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-5474
Practice Address - Country:US
Practice Address - Phone:602-803-4522
Practice Address - Fax:480-621-8109
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-27
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ987208133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered