Provider Demographics
NPI:1932949427
Name:PHELPS, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:PHELPS
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 1:2054 COLDWATER CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-8702
Mailing Address - Country:US
Mailing Address - Phone:317-679-1336
Mailing Address - Fax:
Practice Address - Street 1:2054 COLDWATER CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46239-8702
Practice Address - Country:US
Practice Address - Phone:317-679-1336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN24-017159-1372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN24-017159-1OtherPERSONAL SERVICES AGENCY LICENSE