Provider Demographics
NPI:1356043277
Name:DIRKS, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:DIRKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:GILLILAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:825 S CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-3938
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:825 S CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-3938
Practice Address - Country:US
Practice Address - Phone:410-698-2215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR245538363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner