Provider Demographics
NPI:1679745624
Name:STREET, ANDREA K (BS)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:K
Last Name:STREET
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:K
Other - Last Name:KAZECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:1230 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3166
Mailing Address - Country:US
Mailing Address - Phone:360-636-6268
Mailing Address - Fax:360-575-6749
Practice Address - Street 1:600 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3256
Practice Address - Country:US
Practice Address - Phone:360-636-4943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8510075Medicaid
WAG8873182Medicare PIN