Provider Demographics
NPI:1114028073
Name:ANDERSON, GENEVA J
Entity Type:Individual
Prefix:
First Name:GENEVA
Middle Name:J
Last Name:ANDERSON
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 1:1955 US 1 SOUTH
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5788
Mailing Address - Country:US
Mailing Address - Phone:904-825-5055
Mailing Address - Fax:904-825-5008
Practice Address - Street 1:1955 US 1 SOUTH
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5788
Practice Address - Country:US
Practice Address - Phone:904-825-5055
Practice Address - Fax:904-825-5008
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator