Provider Demographics
NPI:1568951606
Name:GRANT, ANDREA ROSE
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:ROSE
Last Name:GRANT
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 1:3501 LAFAYETTE BLVD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-4130
Mailing Address - Country:US
Mailing Address - Phone:540-371-7118
Mailing Address - Fax:540-371-3248
Practice Address - Street 1:3501 LAFAYETTE BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-4130
Practice Address - Country:US
Practice Address - Phone:540-371-7118
Practice Address - Fax:540-371-3248
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55869363A00000X
VA0110008473363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMW5069922OtherDRUG ENFORCEMENT ADMINISTRATION