Provider Demographics
NPI:1881760510
Name:MACDONALD, ANDREA M (ARNP)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:M
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 E HWY 50
Mailing Address - Street 2:PMB 4
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-2778
Mailing Address - Country:US
Mailing Address - Phone:352-563-8140
Mailing Address - Fax:
Practice Address - Street 1:2000 EDGEWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748
Practice Address - Country:US
Practice Address - Phone:352-787-3545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1749192363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305309100Medicaid
FLY3783AMedicare ID - Type Unspecified
FL305309100Medicaid