Provider Demographics
NPI:1356760391
Name:ACKERSON, ANDREA K (RD IBCLC)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:K
Last Name:ACKERSON
Suffix:
Gender:F
Credentials:RD IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 NORMANDY WAY
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03063-3322
Mailing Address - Country:US
Mailing Address - Phone:518-527-3213
Mailing Address - Fax:
Practice Address - Street 1:5 NORMANDY WAY
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03063-3322
Practice Address - Country:US
Practice Address - Phone:518-527-3213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-07
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY928270133V00000X
CAL56279174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered