Provider Demographics
NPI:1609487008
Name:COFFEE, ANDI M (NUTRITIONIST)
Entity Type:Individual
Prefix:
First Name:ANDI
Middle Name:M
Last Name:COFFEE
Suffix:
Gender:F
Credentials:NUTRITIONIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3613 W SOUSA CT
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-6022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1928 W ST EXUPERY DR
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-3623
Practice Address - Country:US
Practice Address - Phone:602-478-3709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX5894133N00000X
FLND11884133N00000X
AZ18329133N00000X
171400000X, 133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No171400000XOther Service ProvidersHealth & Wellness Coach
Provider Identifiers
StateIdentifier IDID TypeIssuer
167494OtherNUTRITIONIST