Healthcare Provider Details

I. General information

NPI: 1306133095
Provider Name (Legal Business Name): DEBRA L ANDERSON DNP, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEBRA LEE BRODERSEN

II. Dates (important events)

Enumeration Date: 07/01/2011
Last Update Date: 07/16/2022
Certification Date: 07/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 N CHESTNUT STREET
JOHNSON KS
67855-0639
US

IV. Provider business mailing address

PO BOX 639
JOHNSON KS
67855-0639
US

V. Phone/Fax

Practice location:
  • Phone: 620-492-1400
  • Fax: 620-492-1608
Mailing address:
  • Phone: 620-492-1400
  • Fax: 620-492-1608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number108186
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA-108186
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-77305-031
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: