Provider Demographics
NPI:1629713268
Name:DEVIESE, ANDRA SHELL
Entity Type:Individual
Prefix:
First Name:ANDRA
Middle Name:SHELL
Last Name:DEVIESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3564 MARC AVE
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35226-2393
Mailing Address - Country:US
Mailing Address - Phone:904-753-0764
Mailing Address - Fax:
Practice Address - Street 1:3564 MARC AVE
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35226-2393
Practice Address - Country:US
Practice Address - Phone:904-753-0764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3344133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic