Provider Demographics
NPI:1184851255
Name:SHOTTON, ANDREA DAWN (MS RD LD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:DAWN
Last Name:SHOTTON
Suffix:
Gender:F
Credentials:MS RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21333 E 104TH ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-3669
Mailing Address - Country:US
Mailing Address - Phone:918-449-1123
Mailing Address - Fax:
Practice Address - Street 1:21333 E 104TH ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-3669
Practice Address - Country:US
Practice Address - Phone:918-449-1123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2011-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1371133N00000X
OK1659133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05376085Medicaid
OK200255350 BMedicaid
MS05376085Medicaid
OKOK700817Medicare PIN