Healthcare Provider Details

I. General information

NPI: 1255634895
Provider Name (Legal Business Name): ANDREA GAIL SPADER MEDICAL AESTHETICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2010
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1606 NE MIAMI GARDENS DR
N MIAMI BEACH FL
33179-4900
US

IV. Provider business mailing address

1606 NE MIAMI GARDENS DR
N MIAMI BEACH FL
33179-4900
US

V. Phone/Fax

Practice location:
  • Phone: 305-354-8266
  • Fax: 305-354-8280
Mailing address:
  • Phone: 305-354-8266
  • Fax: 305-354-8280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberEO1620
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberFB9722504
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberFB93013
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA50604
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA60818
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: