Provider Demographics
NPI:1902121841
Name:WILSON, ANDREA (RN,BSN)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN,BSN
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:POKORRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1234
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-8234
Mailing Address - Country:US
Mailing Address - Phone:503-397-5211
Mailing Address - Fax:503-397-5373
Practice Address - Street 1:58646 MCNULTY WAY
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-6210
Practice Address - Country:US
Practice Address - Phone:503-397-5211
Practice Address - Fax:503-397-5373
Is Sole Proprietor?:No
Enumeration Date:2010-04-04
Last Update Date:2010-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200942534RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse