Provider Demographics
NPI:1013255066
Name:ADDLEY, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:ADDLEY
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 1:2542 W 2800 S
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83286-5125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1174 E GRAYSTONE WAY STE 1A
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2671
Practice Address - Country:US
Practice Address - Phone:801-664-2182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-26
Last Update Date:2013-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6511772-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered