MEDICARE: ANDREA ELAINE FLEENOR RD

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	:	1407930696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA ELAINE FLEENOR RD

Provider Business Mailing Address
First Line	:	6921 W GORE BLVD
Second Line	:	#516
City	:	LAWTON
State	:	OK
Zip	:	73505-5330
Country	:	US
Telephone Number	:	580-458-3055
Fax Number	:	580-458-2846

Provider Business Practice Location Address
First Line	:	4301 MOW-WAY ROAD
Second Line	:	REYNOLDS ARMY COMMUNITY HOSPITAL (MCUA-QC, MS.PRESCOTT)
City	:	FT. SILL
State	:	OK
Zip	:	73503-6300
Country	:	US
Telephone Number	:	580-458-2134
Fax Number	:	580-458-2314

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

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	07/08/2007

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