Provider Demographics
NPI:1194148866
Name:RICHARDSON, ANDREW (RD, LD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
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 1:4200 SUMMIT CREEK BLVD
Mailing Address - Street 2:9208
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-4510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4200 SUMMIT CREEK BLVD
Practice Address - Street 2:9208
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-4510
Practice Address - Country:US
Practice Address - Phone:440-339-5426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1104473133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered