Provider Demographics
NPI:1912661851
Name:SMITH, ANDREA LYNN (RN)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:LYNN
Other - Last Name:TOCKSTEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:12169 OAK GROVE DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75706-5951
Mailing Address - Country:US
Mailing Address - Phone:618-204-3328
Mailing Address - Fax:
Practice Address - Street 1:12169 OAK GROVE DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75706-5951
Practice Address - Country:US
Practice Address - Phone:618-204-3328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX907763163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse