Provider Demographics
NPI:1942795646
Name:YURISICH, ANDA
Entity Type:Individual
Prefix:
First Name:ANDA
Middle Name:
Last Name:YURISICH
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 1:5534 SAINT JOE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-3328
Mailing Address - Country:US
Mailing Address - Phone:765-343-6393
Mailing Address - Fax:
Practice Address - Street 1:5534 SAINT JOE RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-3328
Practice Address - Country:US
Practice Address - Phone:765-343-6393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR103K00000X
374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst