Provider Demographics
NPI:1205284213
Name:BAILEY, ANDREA L (RD, LD)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:L
Last Name:BAILEY
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2518 N LANCASTER DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-0635
Mailing Address - Country:US
Mailing Address - Phone:208-991-2066
Mailing Address - Fax:
Practice Address - Street 1:2518 N LANCASTER DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-0635
Practice Address - Country:US
Practice Address - Phone:208-991-2066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND-11269133V00000X
NCL007017133V00000X
IDD-1027133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered