Healthcare Provider Details

I. General information

NPI: 1467531921
Provider Name (Legal Business Name): KATHERINE ANDERSEN D.O.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 SOUTH RIO GRANDE AVE. SUITE B
AZTEC NM
87410
US

IV. Provider business mailing address

606 SOUTH RIO GRANDE AVE. SUITE B
AZTEC NM
87410
US

V. Phone/Fax

Practice location:
  • Phone: 505-334-2008
  • Fax: 505-334-5515
Mailing address:
  • Phone: 505-334-2008
  • Fax: 505-334-5515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number208
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: