Healthcare Provider Details

I. General information

NPI: 1578326740
Provider Name (Legal Business Name): DEBORAH ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2024
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10431 LEMON AVE STE N
RANCHO CUCAMONGA CA
91737-3766
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 909-466-6579
  • Fax: 909-466-1389
Mailing address:
  • Phone: 702-579-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95023452
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: