Healthcare Provider Details

I. General information

NPI: 1447708185
Provider Name (Legal Business Name): ANDREA MCDONNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2016
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 58TH ST
VIENNA WV
26105-2027
US

IV. Provider business mailing address

2507 9TH AVE
PARKERSBURG WV
26101-5855
US

V. Phone/Fax

Practice location:
  • Phone: 304-485-6513
  • Fax:
Mailing address:
  • Phone: 304-485-6513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number0749
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: