Provider Demographics
NPI:1740521772
Name:THEDFORD, ANITA ROSE
Entity type:Individual
Prefix:MS
First Name:ANITA
Middle Name:ROSE
Last Name:THEDFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ANITA
Other - Middle Name:ROSE
Other - Last Name:THEDFORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD/LDN
Mailing Address - Street 1:236 BAYSHORE DR
Mailing Address - Street 2:
Mailing Address - City:HEMPHILL
Mailing Address - State:TX
Mailing Address - Zip Code:75948-1380
Mailing Address - Country:US
Mailing Address - Phone:318-581-0301
Mailing Address - Fax:
Practice Address - Street 1:160 N OAK ST
Practice Address - Street 2:
Practice Address - City:HEMPHILL
Practice Address - State:TX
Practice Address - Zip Code:75948-9858
Practice Address - Country:US
Practice Address - Phone:318-581-0301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-15
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT05212133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered