Provider Demographics
NPI:1619093044
Name:LASICHAK, ANDREA JAN (MS, RD, CDE)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:JAN
Last Name:LASICHAK
Suffix:
Gender:F
Credentials:MS, RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8135 STONEHEDGE RD
Mailing Address - Street 2:
Mailing Address - City:GREGORY
Mailing Address - State:MI
Mailing Address - Zip Code:48137-9753
Mailing Address - Country:US
Mailing Address - Phone:734-433-1615
Mailing Address - Fax:
Practice Address - Street 1:8135 STONEHEDGE RD
Practice Address - Street 2:
Practice Address - City:GREGORY
Practice Address - State:MI
Practice Address - Zip Code:48137-9753
Practice Address - Country:US
Practice Address - Phone:734-433-1615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic