Provider Demographics
NPI:1376055004
Name:ANDRADE, JENNY VIVIAN
Entity Type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:VIVIAN
Last Name:ANDRADE
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 1:3904 S OLD HIGHWAY 94 STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63304-2850
Mailing Address - Country:US
Mailing Address - Phone:636-244-0686
Mailing Address - Fax:
Practice Address - Street 1:3904 S OLD HIGHWAY 94 STE 200
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63304-2850
Practice Address - Country:US
Practice Address - Phone:636-244-0686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013031244163W00000X
MO20180009355363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse