Provider Demographics
NPI:1053974055
Name:SIX, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:SIX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8208 KIAWAH TRCE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3027
Mailing Address - Country:US
Mailing Address - Phone:772-529-4227
Mailing Address - Fax:
Practice Address - Street 1:509 SE RIVERSIDE DR STE 100
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2579
Practice Address - Country:US
Practice Address - Phone:772-223-5920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH123136367500000X
390200000X
FLAPRN11003265367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program