Provider Demographics
NPI:1710516281
Name:THACKER, ANNMARIE (RDN, LD, CDCES)
Entity Type:Individual
Prefix:
First Name:ANNMARIE
Middle Name:
Last Name:THACKER
Suffix:
Gender:F
Credentials:RDN, LD, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-3699
Mailing Address - Country:US
Mailing Address - Phone:220-564-4911
Mailing Address - Fax:220-564-4919
Practice Address - Street 1:1865 TAMARACK RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2305
Practice Address - Country:US
Practice Address - Phone:220-564-4911
Practice Address - Fax:220-564-4919
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered