Healthcare Provider Details

I. General information

NPI: 1528523974
Provider Name (Legal Business Name): ANDREA HARTLINE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANDREA HARTLINE PA-C

II. Dates (important events)

Enumeration Date: 02/08/2019
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

IV. Provider business mailing address

36065 SANTA FE AVE
FORT CAVAZOS TX
76544-5060
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-8500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: