Provider Demographics
NPI:1457372898
Name:DOMAS, ANDREA JEAN (RD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:JEAN
Last Name:DOMAS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 W VAN BUREN ST
Mailing Address - Street 2:SUITE 425 TOB
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3218
Mailing Address - Country:US
Mailing Address - Phone:312-942-3438
Mailing Address - Fax:312-942-5203
Practice Address - Street 1:1700 W VAN BUREN ST
Practice Address - Street 2:SUITE 425 TOB
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3218
Practice Address - Country:US
Practice Address - Phone:312-942-3438
Practice Address - Fax:312-942-5203
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered