Healthcare Provider Details

I. General information

NPI: 1134560758
Provider Name (Legal Business Name): ANDREA ELAINE BALLUCH-DEAN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2013
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3610 MERCEDES PL
CANFIELD OH
44406-8139
US

IV. Provider business mailing address

143 BOARDMAN CANFIELD RD STE 324
BOARDMAN OH
44512-4804
US

V. Phone/Fax

Practice location:
  • Phone: 724-866-1750
  • Fax: 724-618-4128
Mailing address:
  • Phone: 724-866-1750
  • Fax: 724-618-4128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number341812
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14803
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.14803
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: