Provider Demographics
NPI:1174402721
Name:NTAVITAGIA, THEONA
Entity type:Individual
Prefix:
First Name:THEONA
Middle Name:
Last Name:NTAVITAGIA
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 HARRISON AVE APT 403
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2363
Mailing Address - Country:US
Mailing Address - Phone:747-319-9008
Mailing Address - Fax:
Practice Address - Street 1:635 ALBANY ST RM 729
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-3550
Practice Address - Country:US
Practice Address - Phone:617-358-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-28
Last Update Date:2025-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL100950390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program