MEDICARE: JODY MARIE ANDERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	PN050009	AZ

General Provider Information

NPI Number	:	1184365439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JODY MARIE ANDERSON

Provider Business Mailing Address
First Line	:	5028 W HARMONT DR
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85302-6323
Country	:	US
Telephone Number	:	623-326-1108
Fax Number	:

Provider Business Practice Location Address
First Line	:	4065 E BELL RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-2208
Country	:	US
Telephone Number	:	602-867-0212
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2022
Last Update Date	:	04/01/2022

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Directions to “ JODY MARIE ANDERSON ” Practice Location

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