Provider Demographics
NPI:1447923719
Name:WILD-GINGELESKI, ANDREA MI
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:MI
Last Name:WILD-GINGELESKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 ELON RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:24572-2536
Mailing Address - Country:US
Mailing Address - Phone:434-455-2480
Mailing Address - Fax:
Practice Address - Street 1:582 BLUE RIDGE AVE
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:VA
Practice Address - Zip Code:24523-2604
Practice Address - Country:US
Practice Address - Phone:434-455-2480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-31
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024181709363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner