Provider Demographics
NPI:1679763478
Name:BALTHAZOR, ANN MARIE (RD CD)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:BALTHAZOR
Suffix:
Gender:F
Credentials:RD CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1933 HORNBLEND ST
Mailing Address - Street 2:APT 21
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-4582
Mailing Address - Country:US
Mailing Address - Phone:920-539-0348
Mailing Address - Fax:
Practice Address - Street 1:1933 HORNBLEND ST
Practice Address - Street 2:APT 21
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-4582
Practice Address - Country:US
Practice Address - Phone:920-539-0348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-27
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA957102133V00000X
OR10146262133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered