Healthcare Provider Details

I. General information

NPI: 1730441411
Provider Name (Legal Business Name): ANDREA MICHELLE LUONGO RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 04/13/2021
Certification Date: 03/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 CHASE OAKS BLVD STE 150
PLANO TX
75023-2383
US

IV. Provider business mailing address

3008 GLENHAVEN DR
PLANO TX
75023-8003
US

V. Phone/Fax

Practice location:
  • Phone: 469-939-1047
  • Fax:
Mailing address:
  • Phone: 469-939-1047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number1036358
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: