Provider Demographics
NPI:1669893996
Name:GROTEVANT, ANNA R (MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:R
Last Name:GROTEVANT
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:R
Other - Last Name:POLUCHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:159 COBURN AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-1112
Mailing Address - Country:US
Mailing Address - Phone:508-272-3613
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:774-443-3887
Practice Address - Fax:774-443-3913
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-06
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3557133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered