Provider Demographics
NPI:1114379047
Name:ANDERSON, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
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 1:4520 GARDNER ST
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-2638
Mailing Address - Country:US
Mailing Address - Phone:586-718-8448
Mailing Address - Fax:
Practice Address - Street 1:4520 GARDNER ST
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-2638
Practice Address - Country:US
Practice Address - Phone:586-718-8448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-02
Last Update Date:2016-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information