Provider Demographics
NPI:1790046605
Name:PERSICO, ANDREA M (MSED)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:M
Last Name:PERSICO
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:RAVENA
Mailing Address - State:NY
Mailing Address - Zip Code:12143-1415
Mailing Address - Country:US
Mailing Address - Phone:518-461-6070
Mailing Address - Fax:
Practice Address - Street 1:44 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:RAVENA
Practice Address - State:NY
Practice Address - Zip Code:12143-1415
Practice Address - Country:US
Practice Address - Phone:518-461-6070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY561815941174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist