Provider Demographics
NPI:1942376637
Name:TETREAULT, JOY KATHLEEN (RD)
Entity Type:Individual
Prefix:MRS
First Name:JOY
Middle Name:KATHLEEN
Last Name:TETREAULT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JOY
Other - Middle Name:KATHLEEN
Other - Last Name:FLICKINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16 LOOMIS ST
Mailing Address - Street 2:
Mailing Address - City:NORTH ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02760-4321
Mailing Address - Country:US
Mailing Address - Phone:508-212-5011
Mailing Address - Fax:
Practice Address - Street 1:211 PARK ST
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-3143
Practice Address - Country:US
Practice Address - Phone:508-236-8039
Practice Address - Fax:508-236-8031
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2091133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMT0558Medicare ID - Type Unspecified