Provider Demographics
NPI:1053069286
Name:VANDERWEIDE, ANNE
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:
Last Name:VANDERWEIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9055 BALBOA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1509
Mailing Address - Country:US
Mailing Address - Phone:907-632-1748
Mailing Address - Fax:
Practice Address - Street 1:9055 BALBOA AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1509
Practice Address - Country:US
Practice Address - Phone:907-632-1748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer