Provider Demographics
NPI:1720523715
Name:THOMAS, TEDDY ANN
Entity Type:Individual
Prefix:
First Name:TEDDY
Middle Name:ANN
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TEDDY
Other - Middle Name:ANN
Other - Last Name:COSTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1925 MOUNTAIN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3128
Mailing Address - Country:US
Mailing Address - Phone:303-776-1234
Mailing Address - Fax:720-494-3107
Practice Address - Street 1:1925 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3128
Practice Address - Country:US
Practice Address - Phone:303-776-1234
Practice Address - Fax:720-494-3107
Is Sole Proprietor?:No
Enumeration Date:2016-12-29
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD0955133V00000X
CO1024756133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered