Provider Demographics
NPI:1760185938
Name:ASSOUAD, ANDREA (CN)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:ASSOUAD
Suffix:
Gender:F
Credentials:CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4126 185TH PL SE
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-9765
Mailing Address - Country:US
Mailing Address - Phone:206-898-3042
Mailing Address - Fax:
Practice Address - Street 1:4126 185TH PL SE
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-9765
Practice Address - Country:US
Practice Address - Phone:206-898-3042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANU61399065133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist