Provider Demographics
NPI:1003124207
Name:WILLIAMS, ANDREA L (RD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:L
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:ANDREA
Other - Middle Name:L
Other - Last Name:GRYSKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1055 S US HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-2437
Mailing Address - Country:US
Mailing Address - Phone:989-224-3000
Mailing Address - Fax:989-224-1424
Practice Address - Street 1:1055 S US HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-2437
Practice Address - Country:US
Practice Address - Phone:989-224-3000
Practice Address - Fax:989-224-1424
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1015680133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered