Healthcare Provider Details

I. General information

NPI: 1982925475
Provider Name (Legal Business Name): ANDREA NICHOLE MCGREW RDN/LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15542 OLD OAK CT
GULFPORT MS
39503-9096
US

IV. Provider business mailing address

15542 OLD OAK CT
GULFPORT MS
39503-9096
US

V. Phone/Fax

Practice location:
  • Phone: 417-825-8847
  • Fax:
Mailing address:
  • Phone: 417-825-8847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2010001121
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD-2179
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: