Healthcare Provider Details

I. General information

NPI: 1205284213
Provider Name (Legal Business Name): ANDREA L BAILEY RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2016
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2518 N LANCASTER DR
BOISE ID
83702-0635
US

IV. Provider business mailing address

2518 N LANCASTER DR
BOISE ID
83702-0635
US

V. Phone/Fax

Practice location:
  • Phone: 208-991-2066
  • Fax:
Mailing address:
  • Phone: 208-991-2066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND-11269
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL007017
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD-1027
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: