Provider Demographics
NPI:1538692736
Name:LEARY, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:LEARY
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:PO BOX 551308
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32255-1308
Mailing Address - Country:US
Mailing Address - Phone:904-622-9040
Mailing Address - Fax:904-309-5691
Practice Address - Street 1:205 ZEAGLER DR STE 101
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3860
Practice Address - Country:US
Practice Address - Phone:386-325-2836
Practice Address - Fax:386-325-2736
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9348971363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily