Provider Demographics
NPI:1285836817
Name:LASSOR, ANDREA KATHLEEN (BS, DT)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:KATHLEEN
Last Name:LASSOR
Suffix:
Gender:F
Credentials:BS, DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246-1616
Mailing Address - Country:US
Mailing Address - Phone:618-664-3663
Mailing Address - Fax:
Practice Address - Street 1:507 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-1616
Practice Address - Country:US
Practice Address - Phone:618-664-3663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILAS05471201P174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist