Provider Demographics
NPI:1821328899
Name:VANN, ANDREA LYNN BODE (MS RD LD)
Entity Type:Individual
Prefix:
First Name:ANDREA LYNN
Middle Name:BODE
Last Name:VANN
Suffix:
Gender:F
Credentials:MS RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 SAINT MICHAEL DR
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-5220
Mailing Address - Country:US
Mailing Address - Phone:903-614-5322
Mailing Address - Fax:
Practice Address - Street 1:2600 SAINT MICHAEL DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-5220
Practice Address - Country:US
Practice Address - Phone:903-614-5322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT80323133V00000X
AR998133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN710000366Medicare PIN