Healthcare Provider Details

I. General information

NPI: 1871563536
Provider Name (Legal Business Name): GRETCHEN L ANDERSON RN, CS, MS(N),FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3917 WEST RD SUITE A
LOS ALAMOS NM
87544-2275
US

IV. Provider business mailing address

3917 WEST RD SUITE A
LOS ALAMOS NM
87544-2275
US

V. Phone/Fax

Practice location:
  • Phone: 505-661-8900
  • Fax: 505-661-8961
Mailing address:
  • Phone: 505-661-8900
  • Fax: 505-661-8961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number102429
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-01819
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: