Healthcare Provider Details

I. General information

NPI: 1720141955
Provider Name (Legal Business Name): MRS. JO ELLEN ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JO ELLEN MONAHAN

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7223 FAIR OAKS BLVD
CARMICHAEL CA
95608
US

IV. Provider business mailing address

205 BITTERCREEK DRIVE
FOLSOM CA
95630
US

V. Phone/Fax

Practice location:
  • Phone: 916-483-9961
  • Fax: 916-483-9998
Mailing address:
  • Phone: 916-983-2899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number7106
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: