Provider Demographics
NPI:1194414151
Name:MONTOYA, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:MONTOYA
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 1:12161 KEN ADAMS WAY STE 110-Y
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-3194
Mailing Address - Country:US
Mailing Address - Phone:561-270-6624
Mailing Address - Fax:
Practice Address - Street 1:12161 KEN ADAMS WAY STE 110-Y
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-3194
Practice Address - Country:US
Practice Address - Phone:561-270-6624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-04
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11026108363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily