Provider Demographics
NPI:1750034021
Name:COLEY, ANDREA DAWN
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:DAWN
Last Name:COLEY
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 1:46198 DEADEND LN
Mailing Address - Street 2:
Mailing Address - City:HEAVENER
Mailing Address - State:OK
Mailing Address - Zip Code:74937-8244
Mailing Address - Country:US
Mailing Address - Phone:254-498-8574
Mailing Address - Fax:
Practice Address - Street 1:46198 DEADEND LN
Practice Address - Street 2:
Practice Address - City:HEAVENER
Practice Address - State:OK
Practice Address - Zip Code:74937-8244
Practice Address - Country:US
Practice Address - Phone:254-498-8574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK205839363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK205839OtherAPRN LICENSE