Healthcare Provider Details

I. General information

NPI: 1962873000
Provider Name (Legal Business Name): ANDREA NICOLE URBAN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2015
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 DUNSMORE LN
WAXHAW NC
28173-8097
US

IV. Provider business mailing address

222 S HERLONG AVE
ROCK HILL SC
29732-1158
US

V. Phone/Fax

Practice location:
  • Phone: 704-608-0526
  • Fax:
Mailing address:
  • Phone: 803-329-6886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL004715
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1425
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86068270
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: