Provider Demographics
NPI:1588321939
Name:MYERS-GRIFFIN, ANDREA ELEASE
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:ELEASE
Last Name:MYERS-GRIFFIN
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 1:6818 W FM 1161 RD
Mailing Address - Street 2:
Mailing Address - City:WHARTON
Mailing Address - State:TX
Mailing Address - Zip Code:77488-9749
Mailing Address - Country:US
Mailing Address - Phone:979-533-4538
Mailing Address - Fax:
Practice Address - Street 1:6818 W FM 1161 RD
Practice Address - Street 2:
Practice Address - City:WHARTON
Practice Address - State:TX
Practice Address - Zip Code:77488-9749
Practice Address - Country:US
Practice Address - Phone:979-533-4538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-19
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX753351163WP0808X
IAG172317363LP0808X
TX1106494363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1Medicaid