Healthcare Provider Details

I. General information

NPI: 1891729398
Provider Name (Legal Business Name): KEITH ERIK ANDERSON RN, NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST RM 7002
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

2513 MOMENTUM PLACE
CHICAGO IL
60689-0001
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-8631
  • Fax: 909-558-0696
Mailing address:
  • Phone: 231-935-6080
  • Fax: 231-935-6081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number491898
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number10439
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704318195
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: