Provider Demographics
NPI:1154996130
Name:PELLERIN, ANDREA N
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:N
Last Name:PELLERIN
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 1:1220 E HOTCHKISS RD
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-8714
Mailing Address - Country:US
Mailing Address - Phone:989-460-7790
Mailing Address - Fax:
Practice Address - Street 1:926 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4323
Practice Address - Country:US
Practice Address - Phone:989-753-8453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-23
Last Update Date:2021-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
176B00000X
MI367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife