Provider Demographics
NPI:1447785902
Name:COX, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:COX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10080 SE SHADY LN
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:OR
Mailing Address - Zip Code:97089-6304
Mailing Address - Country:US
Mailing Address - Phone:971-303-2394
Mailing Address - Fax:855-225-2819
Practice Address - Street 1:511 SE 11TH AVE # 202
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2411
Practice Address - Country:US
Practice Address - Phone:971-303-2394
Practice Address - Fax:855-255-2819
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10172441133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered