Provider Demographics
NPI:1609537604
Name:HODGES, ANDREA LAVELL
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:LAVELL
Last Name:HODGES
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 1:704 CALVIN AVERY DR
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-6500
Mailing Address - Country:US
Mailing Address - Phone:901-896-9626
Mailing Address - Fax:
Practice Address - Street 1:704 CALVIN AVERY DR STE A
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-6536
Practice Address - Country:US
Practice Address - Phone:901-896-9626
Practice Address - Fax:870-394-9391
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR57593747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty