Provider Demographics
NPI:1174183594
Name:WILSON, ANDREA ROSE (AUD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:ROSE
Last Name:WILSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 ANNE ST NW STE G
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-4391
Mailing Address - Country:US
Mailing Address - Phone:218-333-8833
Mailing Address - Fax:218-333-8735
Practice Address - Street 1:677 ANNE ST NW STE G
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-4391
Practice Address - Country:US
Practice Address - Phone:218-333-8833
Practice Address - Fax:218-333-8735
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10264231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist