MEDICARE: ANDREA ADDLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	6511772-4901	UT

General Provider Information

NPI Number	:	1013255066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA ADDLEY

Provider Business Mailing Address
First Line	:	715 RANCH LOOP RD
Second Line	:
City	:	PRESTON
State	:	ID
Zip	:	83263-5116
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1174 E GRAYSTONE WAY STE 1A
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2671
Country	:	US
Telephone Number	:	801-664-2182
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2013
Last Update Date	:	02/05/2025

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