Provider Demographics
NPI:1497215842
Name:JETHWA, VANIKA (LD/RD)
Entity Type:Individual
Prefix:
First Name:VANIKA
Middle Name:
Last Name:JETHWA
Suffix:
Gender:F
Credentials:LD/RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 WESTMINSTER AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119-1595
Mailing Address - Country:US
Mailing Address - Phone:860-371-1907
Mailing Address - Fax:
Practice Address - Street 1:4 WESTMINSTER AVE APT 1
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02119-1595
Practice Address - Country:US
Practice Address - Phone:860-371-1907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALDN4743133V00000X
NH1009133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered