Provider Demographics
NPI:1912494923
Name:WILSON, ANDREA SHERRELL
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:SHERRELL
Last Name:WILSON
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:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:LIGHTFOOT
Mailing Address - State:VA
Mailing Address - Zip Code:23090-0430
Mailing Address - Country:US
Mailing Address - Phone:757-561-8109
Mailing Address - Fax:
Practice Address - Street 1:5339 ARBOR PL
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2469
Practice Address - Country:US
Practice Address - Phone:757-714-1272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA664343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)