Provider Demographics
NPI:1144450198
Name:KOSCIULEK, ANDREA ANDERSON (MS)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:ANDERSON
Last Name:KOSCIULEK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:861439 N HAMPTON CLUB WAY
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-8705
Mailing Address - Country:US
Mailing Address - Phone:904-548-0641
Mailing Address - Fax:
Practice Address - Street 1:861439 N HAMPTON CLUB WAY
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-8705
Practice Address - Country:US
Practice Address - Phone:904-548-0641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA9498235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist