Basic Information
| Provider Information | |||||||||
| NPI: | 1407930696 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLEENOR | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | ELAINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FAVREAU | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | ELAINE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | RD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6921 W GORE BLVD | ||||||||
| Address2: | #516 | ||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735055330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804583055 | ||||||||
| FaxNumber: | 5804582846 | ||||||||
| Practice Location | |||||||||
| Address1: | 4301 MOW-WAY ROAD | ||||||||
| Address2: | REYNOLDS ARMY COMMUNITY HOSPITAL (MCUA-QC, MS.PRESCOTT) | ||||||||
| City: | FT. SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735036300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804582134 | ||||||||
| FaxNumber: | 5804582314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.