Provider Demographics
NPI:1790126399
Name:WILLER, ANDREA YOUNG (FNP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:YOUNG
Last Name:WILLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 E HIGHWAY 22
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65240-1183
Mailing Address - Country:US
Mailing Address - Phone:573-682-5580
Mailing Address - Fax:573-682-1539
Practice Address - Street 1:1021 E HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:MO
Practice Address - Zip Code:65240
Practice Address - Country:US
Practice Address - Phone:573-682-5580
Practice Address - Fax:573-682-1539
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013024402363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily