Provider Demographics
NPI:1083302475
Name:STOCK DILLON, ANDREA (RN)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:STOCK DILLON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:STOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2288 154TH AVE
Mailing Address - Street 2:
Mailing Address - City:MAHNOMEN
Mailing Address - State:MN
Mailing Address - Zip Code:56557-9004
Mailing Address - Country:US
Mailing Address - Phone:218-849-0254
Mailing Address - Fax:
Practice Address - Street 1:2101 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2417
Practice Address - Country:US
Practice Address - Phone:701-239-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR179788-8163W00000X
NDR-32860163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse