Basic Information
| Provider Information | |||||||||
| NPI: | 1710085139 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANTAZIS | ||||||||
| FirstName: | ANN | ||||||||
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| Credential: | MSRD LDN CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 NEPONSET ST FL STREET12 | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016062714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088526175 | ||||||||
| FaxNumber: | 5085952123 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 NEPONSET ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016062714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088526175 | ||||||||
| FaxNumber: | 5085952123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 09/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133N00000X | 150 | MA | N | Dietary & Nutritional Service Providers | Nutritionist | 133V00000X | 150 | MA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 61229 | 01 | FALLON COMMUNITY HEALTH P | OTHER | 7807609 | 01 | AETNA US HEALTHCARE | OTHER | 042472266 | 01 | PRIVATE HEALTHCARE SYSTEM | OTHER | 042472266 | 01 | THREE RIVERS | OTHER | LD0141 | 01 | BLUE CROSS | OTHER | AA16845 | 01 | HARVARD PILGRIM HEALTHCAR | OTHER |