Provider Demographics
NPI:1629120860
Name:BRAVERMAN, ANDREA LOUISE (RD)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:LOUISE
Last Name:BRAVERMAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MADRONE ST
Mailing Address - Street 2:
Mailing Address - City:WILLITS
Mailing Address - State:CA
Mailing Address - Zip Code:95490-4225
Mailing Address - Country:US
Mailing Address - Phone:707-456-3132
Mailing Address - Fax:707-456-3032
Practice Address - Street 1:1 MADRONE ST
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-4225
Practice Address - Country:US
Practice Address - Phone:707-456-3132
Practice Address - Fax:707-456-3032
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR362093133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered