Provider Demographics
NPI:1164908414
Name:FARRIS, ANDREA LEIGH
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LEIGH
Last Name:FARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24654 N LAKE PLEASANT PKWY STE 103-715
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-1359
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24654 N LAKE PLEASANT PKWY STE 103-715
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-1359
Practice Address - Country:US
Practice Address - Phone:623-399-9891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN124247163WR0006X
AZ219370363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant