Provider Demographics
NPI:1730290503
Name:WILSON, ANDREA LEIGH (NP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LEIGH
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 WAYLAND DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-2041
Mailing Address - Country:US
Mailing Address - Phone:817-548-0061
Mailing Address - Fax:
Practice Address - Street 1:1290 HIGHWAY 157 N
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-1538
Practice Address - Country:US
Practice Address - Phone:817-473-0277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX581634363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily