Provider Demographics
NPI:1821866401
Name:DEMARIA, ANDREA D (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:D
Last Name:DEMARIA
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 S LAUREL RD STE 1
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40744-8300
Mailing Address - Country:US
Mailing Address - Phone:606-770-5086
Mailing Address - Fax:863-456-1301
Practice Address - Street 1:95 S LAUREL RD STE 1
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40744-8300
Practice Address - Country:US
Practice Address - Phone:606-770-5086
Practice Address - Fax:863-456-1301
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000200386163WP0808X
TN36635363LP0808X
KY4025009363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7101023360Medicaid