Provider Demographics
NPI:1730785130
Name:VILLA, ANDREA SARAH (MA60969294)
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:SARAH
Last Name:VILLA
Suffix:
Gender:F
Credentials:MA60969294
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:WAITSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:99361-9774
Mailing Address - Country:US
Mailing Address - Phone:509-676-9049
Mailing Address - Fax:
Practice Address - Street 1:131 MAIN ST.
Practice Address - Street 2:
Practice Address - City:WAITSBURG
Practice Address - State:WA
Practice Address - Zip Code:99361
Practice Address - Country:US
Practice Address - Phone:509-676-9049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60969294225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist