Healthcare Provider Details

I. General information

NPI: 1295779882
Provider Name (Legal Business Name): MRS. RENATA ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2237 SW COURT AVE
PENDLETON OR
97801-1896
US

IV. Provider business mailing address

2237 SW COURT AVE
PENDLETON OR
97801-1896
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-5053
  • Fax: 541-276-5112
Mailing address:
  • Phone: 541-276-5053
  • Fax: 541-276-5112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberHAS-P-027200
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: