Provider Demographics
NPI:1629636725
Name:PAUL, ANDREA (RDN, LD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:PAUL
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 TUCKER AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1422
Mailing Address - Country:US
Mailing Address - Phone:207-468-3074
Mailing Address - Fax:
Practice Address - Street 1:33 TUCKER AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1422
Practice Address - Country:US
Practice Address - Phone:207-468-3074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI1163133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty