Provider Demographics
NPI:1700820495
Name:ANDRADE, JEANETTE
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:ANDRADE
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 1:822 E KERR AVE
Mailing Address - Street 2:APT 101
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61802-2045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PROVENA UNITED SAMARITANS MEDICAL CENTER
Practice Address - Street 2:812 N LOGAN AVE
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3752
Practice Address - Country:US
Practice Address - Phone:217-443-5000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered