Basic Information
| Provider Information | |||||||||
| NPI: | 1154395721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEMERS | ||||||||
| FirstName: | ANDREA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 RESERVOIR AVE STE 6A | ||||||||
| Address2: | |||||||||
| City: | CRANSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029104450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4019446889 | ||||||||
| FaxNumber: | 4019446726 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 RESERVOIR AVE STE 6A | ||||||||
| Address2: | |||||||||
| City: | CRANSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029104450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018294446 | ||||||||
| FaxNumber: | 4018294434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 02/21/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 208133 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | APRN01313 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363L00000X | NPP37469 | RI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 110015668A | 05 | MA | MEDICAID |