Provider Demographics
NPI:1639481336
Name:WEISS, ANDREA NICOLE (RD)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:NICOLE
Last Name:WEISS
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 1:9361 PASCAL WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-4634
Mailing Address - Country:US
Mailing Address - Phone:916-627-5453
Mailing Address - Fax:
Practice Address - Street 1:701 E CHANNEL ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2628
Practice Address - Country:US
Practice Address - Phone:209-944-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00984906133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00984906OtherCOMMISSION ON DIETETIC REGISTRATION