Basic Information
| Provider Information | |||||||||
| NPI: | 1790126399 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLER | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | YOUNG | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1021 E HIGHWAY 22 | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652401183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736825580 | ||||||||
| FaxNumber: | 5736821539 | ||||||||
| Practice Location | |||||||||
| Address1: | 1021 E HIGHWAY 22 | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736825580 | ||||||||
| FaxNumber: | 5736821539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2013 | ||||||||
| LastUpdateDate: | 09/06/2018 | ||||||||
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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 | 363LF0000X | 2013024402 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.