Provider Demographics
NPI:1760451025
Name:FORDE, ANDREA M (NP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:M
Last Name:FORDE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:M
Other - Last Name:ENOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8053
Mailing Address - Fax:617-421-3487
Practice Address - Street 1:485 ARSENAL ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-5091
Practice Address - Country:US
Practice Address - Phone:617-972-5100
Practice Address - Fax:617-972-5439
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA235173363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAA34081OtherHARVARD PILGRIM
MANP5011OtherBLUE CROSS
MA0703737Medicaid
MANP5011Medicare ID - Type Unspecified
MAQ43518Medicare UPIN