Provider Demographics
NPI:1114538519
Name:ANDERSON, CARRIE NICOLE (CGC)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:NICOLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6251 KINGSGATE DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41005-9284
Mailing Address - Country:US
Mailing Address - Phone:859-486-1559
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:FLOOR 3 - MFM
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-4101
Practice Address - Country:US
Practice Address - Phone:859-301-9475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY223170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS