Basic Information
| Provider Information | |||||||||
| NPI: | 1760451025 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORDE | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ENOS | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 147 MILK ST | ||||||||
| Address2: | PROVIDER ENROLLMENT - 9TH FLOOR | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021094806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175598053 | ||||||||
| FaxNumber: | 6174213487 | ||||||||
| Practice Location | |||||||||
| Address1: | 485 ARSENAL ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024725091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179725100 | ||||||||
| FaxNumber: | 6179725439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 235173 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 235173 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | AA34081 | 01 | MA | HARVARD PILGRIM | OTHER | NP5011 | 01 | MA | BLUE CROSS | OTHER | 0703737 | 05 | MA | MEDICAID |