Provider Demographics
NPI:1467782185
Name:THACKER, ANNE T (LD)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:T
Last Name:THACKER
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:T
Other - Last Name:DICELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9930 JOHNNYCAKE RIDGE RD STE 6B
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6766
Mailing Address - Country:US
Mailing Address - Phone:440-357-6677
Mailing Address - Fax:440-357-6681
Practice Address - Street 1:4614 PROSPECT AVE
Practice Address - Street 2:STE 325
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-4377
Practice Address - Country:US
Practice Address - Phone:216-777-2136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-31
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD 5190133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered