Provider Demographics
NPI:1710547450
Name:RULL, ANDREA NICOLE
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:NICOLE
Last Name:RULL
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 1:109 S HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:BUNKER HILL
Mailing Address - State:IL
Mailing Address - Zip Code:62014-1433
Mailing Address - Country:US
Mailing Address - Phone:618-420-2996
Mailing Address - Fax:
Practice Address - Street 1:502 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:IL
Practice Address - Zip Code:62012-1042
Practice Address - Country:US
Practice Address - Phone:618-372-3232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-15
Last Update Date:2019-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242005356235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist