Provider Demographics
NPI:1669952289
Name:ANTAYA, REBECCA (RDN, IBCLC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:ANTAYA
Suffix:
Gender:F
Credentials:RDN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10048 SWITCHGRASS LN
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-8432
Mailing Address - Country:US
Mailing Address - Phone:616-403-0786
Mailing Address - Fax:
Practice Address - Street 1:10048 SWITCHGRASS LN
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-8432
Practice Address - Country:US
Practice Address - Phone:616-403-0786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
846899133V00000X
L-141903174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered