Basic Information
| Provider Information | |||||||||
| NPI: | 1003566944 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | DEANNA | ||||||||
| MiddleName: | RUTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1016 VALPARAISO BLVD | ||||||||
| Address2: | |||||||||
| City: | NICEVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325783500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252768226 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 MAR WALT DR | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508621111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2022 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | ND9720 | FL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.