Provider Demographics
NPI:1225012800
Name:DIEVENDORF, ANDREA LILLY (DC)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:LILLY
Last Name:DIEVENDORF
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CHELSEA PL
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3227
Mailing Address - Country:US
Mailing Address - Phone:518-373-6545
Mailing Address - Fax:
Practice Address - Street 1:2 CHELSEA PL
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-3227
Practice Address - Country:US
Practice Address - Phone:518-373-6545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX0108561111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
2601222001OtherBSNENY
7016671OtherAETNA
NY23902OtherMVP
NY23902OtherMVP
7016671OtherAETNA