Healthcare Provider Details

I. General information

NPI: 1669293106
Provider Name (Legal Business Name): DEBORAH ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 N MARENGO AVE
PASADENA CA
91103-2217
US

IV. Provider business mailing address

1230 N MARENGO AVE
PASADENA CA
91103-2217
US

V. Phone/Fax

Practice location:
  • Phone: 626-794-1124
  • Fax:
Mailing address:
  • Phone: 626-794-1124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number148135
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: