Healthcare Provider Details

I. General information

NPI: 1265921399
Provider Name (Legal Business Name): ANDREA LYNNE ANDERSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 ROBBINS ST
WATERBURY CT
06708-2613
US

IV. Provider business mailing address

64 ROBBINS ST
WATERBURY CT
06708-2613
US

V. Phone/Fax

Practice location:
  • Phone: 203-573-6000
  • Fax:
Mailing address:
  • Phone: 203-815-7206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4256
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: