Provider Demographics
NPI:1083939441
Name:NUNNALLY, ANDREA (MS)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:NUNNALLY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4528 NW CHEYENNE AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-3245
Mailing Address - Country:US
Mailing Address - Phone:580-695-8411
Mailing Address - Fax:
Practice Address - Street 1:807 SW F AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-4506
Practice Address - Country:US
Practice Address - Phone:580-595-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731-54-5165Medicaid