Provider Demographics
NPI:1639580236
Name:DISTEFANO, ANDREA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 SOLANA RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2231
Mailing Address - Country:US
Mailing Address - Phone:904-273-2717
Mailing Address - Fax:904-273-0410
Practice Address - Street 1:103 SOLANA RD
Practice Address - Street 2:SUITE B
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-2231
Practice Address - Country:US
Practice Address - Phone:904-273-2717
Practice Address - Fax:904-273-0410
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9262502363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
9262502OtherFL ARNP LICENSE #