Provider Demographics
NPI:1598355448
Name:PHELPS, ANDREA MONIQUE
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:MONIQUE
Last Name:PHELPS
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 1:221 OUTER BELLE RD APT A
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45426-1538
Mailing Address - Country:US
Mailing Address - Phone:937-626-4575
Mailing Address - Fax:937-715-4049
Practice Address - Street 1:221 OUTER BELLE RD APT A
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45426-1538
Practice Address - Country:US
Practice Address - Phone:937-307-9639
Practice Address - Fax:937-715-4049
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHF2L5L5E5246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHF2L5L5E5OtherNHA