Provider Demographics
NPI:1003881996
Name:ANDERSON, JEANNINE SUSAN (ARNP)
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:SUSAN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:JEANNINE
Other - Middle Name:SUSAN
Other - Last Name:CONRADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2808 E CENTRAL
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214
Mailing Address - Country:US
Mailing Address - Phone:316-440-4060
Mailing Address - Fax:316-440-4058
Practice Address - Street 1:2808 E CENTRAL
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214
Practice Address - Country:US
Practice Address - Phone:316-440-4060
Practice Address - Fax:316-440-4058
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS74510364SP0808X
KS1346573022163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Not Answered163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
S57351Medicare UPIN