Provider Demographics
NPI:1467628511
Name:GROVE, ANDREA THERESA (LPN)
Entity Type:Individual
Prefix:MISS
First Name:ANDREA
Middle Name:THERESA
Last Name:GROVE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13918 232ND ST
Mailing Address - Street 2:
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413-2927
Mailing Address - Country:US
Mailing Address - Phone:917-767-4304
Mailing Address - Fax:
Practice Address - Street 1:164 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-3046
Practice Address - Country:US
Practice Address - Phone:347-787-1045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY240710-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse