Basic Information
| Provider Information | |||||||||
| NPI: | 1407009251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YESALIS | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP, PHD, CCD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2405 ATHERHOLT RD | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245012184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4344858500 | ||||||||
| FaxNumber: | 4344858599 | ||||||||
| Practice Location | |||||||||
| Address1: | 2405 ATHERHOLT RD | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245012184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4344858500 | ||||||||
| FaxNumber: | 4344858599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2008 | ||||||||
| LastUpdateDate: | 09/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0001236204 | VA | N | Nursing Service Providers | Registered Nurse | 363L00000X | RN285740L | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | SP010069 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 0024169954 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1407009251 | 05 | VA | MEDICAID |