Provider Demographics
NPI:1639823198
Name:ANDERSON, ANDREA (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:
Last Name:ANDERSON
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:PO BOX 6278
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-0278
Mailing Address - Country:US
Mailing Address - Phone:817-568-5467
Mailing Address - Fax:817-568-5474
Practice Address - Street 1:1757 BROAD PARK CIR N STE 201
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-7839
Practice Address - Country:US
Practice Address - Phone:817-806-1130
Practice Address - Fax:817-806-1133
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-03
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1069450363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1639823198Medicaid