Provider Demographics
NPI:1093222408
Name:ANDICH, MARY ESTHER (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ESTHER
Last Name:ANDICH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 SLATER ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-3352
Mailing Address - Country:US
Mailing Address - Phone:707-364-8903
Mailing Address - Fax:
Practice Address - Street 1:2800 CLEVELAND AVE STE A
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2784
Practice Address - Country:US
Practice Address - Phone:707-921-7447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95006919363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2017020150OtherAANC CERTIFICATION