Healthcare Provider Details

I. General information

NPI: 1376095596
Provider Name (Legal Business Name): DR. ANDREA'S MEDICAL & WEIGHT LOSS CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8317 CORDOVA RD SUITE 201
CORDOVA TN
38016-2088
US

IV. Provider business mailing address

8317 CORDOVA RD SUITE 201
CORDOVA TN
38016-2088
US

V. Phone/Fax

Practice location:
  • Phone: 901-573-6765
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberAPN0000011998
License Number StateTN

VIII. Authorized Official

Name: DR. ANDRE WALKER
Title or Position: OWNER
Credential: DNP, FNP-C
Phone: 901-573-6765