Provider Demographics
NPI:1730320573
Name:PANACCIONE, ANDREA LYN (RD)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:LYN
Last Name:PANACCIONE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:ANDREA
Other - Middle Name:LYN
Other - Last Name:STRUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:774 NEWMAN SPRINGS RD
Mailing Address - Street 2:PO BOX 351
Mailing Address - City:LINCROFT
Mailing Address - State:NJ
Mailing Address - Zip Code:07738-1608
Mailing Address - Country:US
Mailing Address - Phone:732-687-0791
Mailing Address - Fax:
Practice Address - Street 1:95 SHELBERN DR
Practice Address - Street 2:
Practice Address - City:LINCROFT
Practice Address - State:NJ
Practice Address - Zip Code:07738-1326
Practice Address - Country:US
Practice Address - Phone:732-687-0791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-06
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ000910110133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered