Provider Demographics
NPI:1043632979
Name:ANDERLE, MAGDALENA (LMT)
Entity Type:Individual
Prefix:
First Name:MAGDALENA
Middle Name:
Last Name:ANDERLE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 441
Mailing Address - Street 2:
Mailing Address - City:RIBERA
Mailing Address - State:NM
Mailing Address - Zip Code:87560-0441
Mailing Address - Country:US
Mailing Address - Phone:415-798-7508
Mailing Address - Fax:
Practice Address - Street 1:1600 LENA ST
Practice Address - Street 2:BUILDING C, # 16
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3891
Practice Address - Country:US
Practice Address - Phone:505-216-1661
Practice Address - Fax:505-216-1661
Is Sole Proprietor?:No
Enumeration Date:2014-01-12
Last Update Date:2014-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7380174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist