Provider Demographics
NPI:1083336234
Name:ANDERSON, DEIDRA DIANE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:DEIDRA
Middle Name:DIANE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:896 BANTA RD
Mailing Address - Street 2:
Mailing Address - City:LOWPOINT
Mailing Address - State:IL
Mailing Address - Zip Code:61545-7580
Mailing Address - Country:US
Mailing Address - Phone:309-208-2935
Mailing Address - Fax:
Practice Address - Street 1:133 SPINDER DR
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-0016
Practice Address - Country:US
Practice Address - Phone:309-308-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209026249363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty