Healthcare Provider Details

I. General information

NPI: 1053021246
Provider Name (Legal Business Name): MEL ANN ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2022
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 MEADOWVIEW DR
PERU IN
46970-8996
US

IV. Provider business mailing address

269 MEADOWVIEW DR
PERU IN
46970-8996
US

V. Phone/Fax

Practice location:
  • Phone: 765-472-8049
  • Fax: 765-475-8895
Mailing address:
  • Phone: 765-472-8049
  • Fax: 765-475-8895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number27075656A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: