Healthcare Provider Details

I. General information

NPI: 1902261621
Provider Name (Legal Business Name): ANDREA OBRIEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 12/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8782 N WYMAN RD
EDMORE MI
48829-9702
US

IV. Provider business mailing address

8782 N WYMAN RD
EDMORE MI
48829-9702
US

V. Phone/Fax

Practice location:
  • Phone: 912-592-1630
  • Fax:
Mailing address:
  • Phone: 912-592-1630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704315880
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: