Healthcare Provider Details

I. General information

NPI: 1003881103
Provider Name (Legal Business Name): KISHA TAMARA ANDERSON APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 07/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 WASHINGTON ST
NEWARK NJ
07102-3026
US

IV. Provider business mailing address

312 STUYVESANT AVE
NEWARK NJ
07106-3637
US

V. Phone/Fax

Practice location:
  • Phone: 973-622-3900
  • Fax: 973-622-1698
Mailing address:
  • Phone: 973-399-5265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number26NN11131200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: