Provider Demographics
NPI:1568470813
Name:MIDAMBA, BLONDELLE ANDREA (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:BLONDELLE
Middle Name:ANDREA
Last Name:MIDAMBA
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 1:20814 CLARE AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-2408
Mailing Address - Country:US
Mailing Address - Phone:440-526-3030
Mailing Address - Fax:440-546-2739
Practice Address - Street 1:10000 BRECKSVILLE RD
Practice Address - Street 2:
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141-3204
Practice Address - Country:US
Practice Address - Phone:440-526-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4367133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered