Healthcare Provider Details

I. General information

NPI: 1043859275
Provider Name (Legal Business Name): MS. KRISTIN S ANDRES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10850 S US HIGHWAY 1 STE 2
PORT ST LUCIE FL
34952-6407
US

IV. Provider business mailing address

150 W UNIVERSITY BLVD
MELBOURNE FL
32901-6982
US

V. Phone/Fax

Practice location:
  • Phone: 772-463-0444
  • Fax: 772-219-1339
Mailing address:
  • Phone: 321-674-8106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-47967
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: