Provider Demographics
NPI:1316272388
Name:DOUGLAS, ANDRE LESTINA (FNP-BC, PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:ANDRE
Middle Name:LESTINA
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:FNP-BC, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14355 MIRANDA WAY
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-2032
Mailing Address - Country:US
Mailing Address - Phone:888-731-8994
Mailing Address - Fax:888-732-8199
Practice Address - Street 1:15333 N PIMA RD STE 305
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-2717
Practice Address - Country:US
Practice Address - Phone:888-731-8994
Practice Address - Fax:888-732-8119
Is Sole Proprietor?:No
Enumeration Date:2009-10-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR51754363LP0808X
VA0024168512363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVB272BMedicare PIN