Healthcare Provider Details

I. General information

NPI: 1336190628
Provider Name (Legal Business Name): BARBARA ANDRESEN RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3447 ROBINHOOD RD SUITE 209
WINSTON SALEM NC
27106-4791
US

IV. Provider business mailing address

3447 ROBINHOOD RD SUITE 209
WINSTON SALEM NC
27106-4791
US

V. Phone/Fax

Practice location:
  • Phone: 336-659-8622
  • Fax: 336-774-1701
Mailing address:
  • Phone: 336-659-8622
  • Fax: 336-774-1701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number000128
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: