Provider Demographics
NPI:1417501081
Name:DUDENHOEFER, ANDREA ROSE (RD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:ROSE
Last Name:DUDENHOEFER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5917 MYSTIC RDG
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-7042
Mailing Address - Country:US
Mailing Address - Phone:814-403-0753
Mailing Address - Fax:
Practice Address - Street 1:5917 MYSTIC RDG
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-7042
Practice Address - Country:US
Practice Address - Phone:814-403-0753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA86108941133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA86108941Medicaid