MEDICARE: PAVLINA NICHOLAS ANTIMISIARIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1346188794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAVLINA NICHOLAS ANTIMISIARIS

Provider Business Mailing Address
First Line	:	1376 HARTLAND WOODS WAY
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40515-2004
Country	:	US
Telephone Number	:	859-693-7619
Fax Number	:

Provider Business Practice Location Address
First Line	:	1376 HARTLAND WOODS WAY
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40515-2004
Country	:	US
Telephone Number	:	859-693-7619
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2026
Last Update Date	:	03/24/2026

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