Provider Demographics
NPI:1902394190
Name:WILSON, ANDREA J
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:J
Last Name:WILSON
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 1:240 E RENSSELAER ST
Mailing Address - Street 2:
Mailing Address - City:BUCYRUS
Mailing Address - State:OH
Mailing Address - Zip Code:44820-2300
Mailing Address - Country:US
Mailing Address - Phone:419-569-3800
Mailing Address - Fax:
Practice Address - Street 1:151 MARION AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2223
Practice Address - Country:US
Practice Address - Phone:419-774-9969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator