Healthcare Provider Details

I. General information

NPI: 1306078456
Provider Name (Legal Business Name): ANDREA BRIGGS OLDS RD LD/N
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2009
Last Update Date: 05/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3221 TAMIAMI TRL
PORT CHARLOTTE FL
33952-8002
US

IV. Provider business mailing address

3221 TAMIAMI TRL
PORT CHARLOTTE FL
33952-8002
US

V. Phone/Fax

Practice location:
  • Phone: 941-505-8720
  • Fax: 941-505-8747
Mailing address:
  • Phone: 941-505-8720
  • Fax: 941-505-0156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberND2794
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: