Provider Demographics
NPI:1275888562
Name:GAINES, ANDREA MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:MICHELLE
Last Name:GAINES
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 1:11 LAUREL TRL
Mailing Address - Street 2:
Mailing Address - City:SAG HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11963-2409
Mailing Address - Country:US
Mailing Address - Phone:631-899-3692
Mailing Address - Fax:
Practice Address - Street 1:11 LAUREL TRL
Practice Address - Street 2:
Practice Address - City:SAG HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11963-2409
Practice Address - Country:US
Practice Address - Phone:631-899-3692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist