Provider Demographics
NPI:1134520794
Name:RESER, ANDREA L (MS, RD, CSO, LD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:L
Last Name:RESER
Suffix:
Gender:F
Credentials:MS, RD, CSO, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S 22ND ST
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-2601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 S 22ND ST
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:OK
Practice Address - Zip Code:74021-2601
Practice Address - Country:US
Practice Address - Phone:918-693-6977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-14
Last Update Date:2014-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1619133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered