Provider Demographics
NPI:1275009516
Name:JANECZEK, KATHRYN ANNE
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANNE
Last Name:JANECZEK
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 1:1 INDIGO LN
Mailing Address - Street 2:
Mailing Address - City:WESTFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01886-4042
Mailing Address - Country:US
Mailing Address - Phone:978-846-2901
Mailing Address - Fax:
Practice Address - Street 1:57 OLD ROAD TO 9 ACRE COR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-3317
Practice Address - Country:US
Practice Address - Phone:978-846-2901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-14
Last Update Date:2018-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4671-NU-NU133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty