Provider Demographics
NPI:1013282920
Name:DUFRESNE, ANDREA L (MSH, RD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:L
Last Name:DUFRESNE
Suffix:
Gender:F
Credentials:MSH, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1276 RUSHING DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-7371
Mailing Address - Country:US
Mailing Address - Phone:904-333-6760
Mailing Address - Fax:
Practice Address - Street 1:18945 FM 2252
Practice Address - Street 2:SUITE 115
Practice Address - City:GARDEN RIDGE
Practice Address - State:TX
Practice Address - Zip Code:78266-2562
Practice Address - Country:US
Practice Address - Phone:210-564-6602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1022343133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered