Provider Demographics
NPI:1316440399
Name:WING, ANDREA NICOLE (APRN)
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:NICOLE
Last Name:WING
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:ANDREA
Other - Middle Name:NICOLE
Other - Last Name:GREENOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-2731
Practice Address - Fax:774-442-4672
Is Sole Proprietor?:No
Enumeration Date:2018-03-15
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2330347363L00000X
NH059093-23363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner