Healthcare Provider Details

I. General information

NPI: 1568714723
Provider Name (Legal Business Name): KATIE ANDERSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2012
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4005 COMMUNITY CENTER DR
WESTON WI
54476-4139
US

IV. Provider business mailing address

4005 COMMUNITY CENTER DR
WESTON WI
54476-4139
US

V. Phone/Fax

Practice location:
  • Phone: 715-241-5404
  • Fax:
Mailing address:
  • Phone: 715-241-5404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5085-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: