Healthcare Provider Details

I. General information

NPI: 1548609431
Provider Name (Legal Business Name): BIANCA MARIA ANDERSON MS, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BIANCA MARIA TERAN

II. Dates (important events)

Enumeration Date: 06/24/2013
Last Update Date: 09/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N BEAVER ST PAYER CREDENTIALING
FLAGSTAFF AZ
86001-3118
US

IV. Provider business mailing address

1200 N BEAVER ST PAYER CREDENTIALING
FLAGSTAFF AZ
86001-3118
US

V. Phone/Fax

Practice location:
  • Phone: 928-773-2054
  • Fax: 928-773-2286
Mailing address:
  • Phone: 928-213-6235
  • Fax: 928-213-6292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1031781
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: