Provider Demographics
NPI:1447317672
Name:ANDERSEN, VICTORIA ANN (MS, RD)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ANN
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 LEON STREET
Mailing Address - Street 2:#1
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-4765
Mailing Address - Country:US
Mailing Address - Phone:508-856-1993
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:508-856-1993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2034133V00000X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Not Answered133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAN MT0508Medicare ID - Type Unspecified