Provider Demographics
NPI:1144307372
Name:ILLE, ANDREA DIONNE (PT)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:DIONNE
Last Name:ILLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11120 ROCK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-5721
Mailing Address - Country:US
Mailing Address - Phone:405-752-1272
Mailing Address - Fax:
Practice Address - Street 1:11120 ROCK RIDGE RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-5721
Practice Address - Country:US
Practice Address - Phone:405-752-1272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1513171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor