Provider Demographics
NPI:1114566015
Name:BROGDON, ANDREA NICOLE (LAC)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:NICOLE
Last Name:BROGDON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 S. COLLEGE AVE.
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525
Mailing Address - Country:US
Mailing Address - Phone:970-222-0575
Mailing Address - Fax:
Practice Address - Street 1:2501 S. COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525
Practice Address - Country:US
Practice Address - Phone:970-222-0575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU.0002532171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist