Healthcare Provider Details

I. General information

NPI: 1477154904
Provider Name (Legal Business Name): KATHY ANDERSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 RIVERSIDE PLAZA LN NW STE 100
ALBUQUERQUE NM
87120-1908
US

IV. Provider business mailing address

6300 RIVERSIDE PLAZA LN NW STE 100
ALBUQUERQUE NM
87120-1908
US

V. Phone/Fax

Practice location:
  • Phone: 505-717-2449
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number69944
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: