Healthcare Provider Details

I. General information

NPI: 1487612529
Provider Name (Legal Business Name): ANDREA Y PROVAN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 CAMPUS RD
ANNANDALE ON HUDSON NY
12504-9800
US

IV. Provider business mailing address

4663 ROUTE 9G
GERMANTOWN NY
12526-5128
US

V. Phone/Fax

Practice location:
  • Phone: 845-758-7433
  • Fax: 845-758-7437
Mailing address:
  • Phone: 518-537-7678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number331217
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: