Provider Demographics
NPI:1578568630
Name:ERICKSON, ANDREA DENISE (RD, CD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:DENISE
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:D
Other - Last Name:LOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:675 S. WHITNEY WAY
Mailing Address - Street 2:WEST GATE HY-VEE
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711
Mailing Address - Country:US
Mailing Address - Phone:608-277-6735
Mailing Address - Fax:608-276-5719
Practice Address - Street 1:675 S. WHITNEY WAY
Practice Address - Street 2:WEST GATE HY-VEE
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711
Practice Address - Country:US
Practice Address - Phone:608-277-6735
Practice Address - Fax:608-276-5719
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1614133V00000X
884951133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1033Medicare PIN