Provider Demographics
NPI:1043284847
Name:TELLISON, ANDREA MICHELLE (CEO)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:MICHELLE
Last Name:TELLISON
Suffix:
Gender:F
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4415 WAVERTREE DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-2949
Mailing Address - Country:US
Mailing Address - Phone:281-499-8503
Mailing Address - Fax:281-403-1421
Practice Address - Street 1:4415 WAVERTREE DR
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-2949
Practice Address - Country:US
Practice Address - Phone:281-499-8503
Practice Address - Fax:281-403-1421
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0065196171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4646430001Medicare NSC