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General NPI Number Information
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NPI Number | 1285836817
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Entity Type | Individual
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Provider Name | ANDREA KATHLEEN LASSOR B.S, D.T.
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Gender | Female
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Dates
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Enumeration Date | 06/05/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 507 W MAIN ST
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City | GREENVILLE
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State | IL
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Zip | 62246-1616
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Country | US
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Telephone | 618-664-3663
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Fax |
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Provider Business Mailing Address
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Address Line | 507 W MAIN ST
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City | GREENVILLE
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State | IL
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Zip | 62246-1616
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Country | US
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Telephone | 618-664-3663
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | AS05471201P
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License Number State | IL
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