Provider Demographics
NPI:1164046918
Name:MCKERRELL, ANDREA NICOLE (OD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:NICOLE
Last Name:MCKERRELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 BLACK FOREST RD
Mailing Address - Street 2:
Mailing Address - City:GLEN SPEY
Mailing Address - State:NY
Mailing Address - Zip Code:12737-8513
Mailing Address - Country:US
Mailing Address - Phone:845-649-2948
Mailing Address - Fax:
Practice Address - Street 1:128 BAILEY FARM RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-4952
Practice Address - Country:US
Practice Address - Phone:845-655-6049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-07
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NYTUV009311152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program