Provider Demographics
NPI:1851761639
Name:TYRRELL, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:TYRRELL
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 1:99 PINEHURST RD
Mailing Address - Street 2:POB 36
Mailing Address - City:CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:94516-9800
Mailing Address - Country:US
Mailing Address - Phone:925-708-1827
Mailing Address - Fax:
Practice Address - Street 1:99 PINEHURST RD
Practice Address - Street 2:750 RIDGECREST RD
Practice Address - City:CANYON
Practice Address - State:CA
Practice Address - Zip Code:94516
Practice Address - Country:US
Practice Address - Phone:925-708-1827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59127225700000X
CA10780374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist