Provider Demographics
NPI:1174183594
Name:WILSON, ANDREA ROSE (AUD)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:ROSE
Last Name:WILSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 300
Mailing Address - Street 2:
Mailing Address - City:FOSSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56542-0300
Mailing Address - Country:US
Mailing Address - Phone:218-435-1210
Mailing Address - Fax:218-435-1175
Practice Address - Street 1:103 1ST ST W
Practice Address - Street 2:
Practice Address - City:FOSSTON
Practice Address - State:MN
Practice Address - Zip Code:56542-1212
Practice Address - Country:US
Practice Address - Phone:219-435-1210
Practice Address - Fax:218-435-1175
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2024-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10264231H00000X
MN528834235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist