Provider Demographics
NPI:1366994485
Name:BUKOWSKI, ANDREA (RD, CD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BUKOWSKI
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 775383
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-5383
Mailing Address - Country:US
Mailing Address - Phone:812-376-5315
Mailing Address - Fax:
Practice Address - Street 1:815 SCHNIER ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-2619
Practice Address - Country:US
Practice Address - Phone:812-376-5780
Practice Address - Fax:812-376-5781
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN949620133V00000X
IN37001777A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered