Provider Demographics
NPI:1265507750
Name:ANDERSON, SUE ANN (MS,APRN, BC, FNP)
Entity Type:Individual
Prefix:MRS
First Name:SUE
Middle Name:ANN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MS,APRN, BC, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52130 S LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-7843
Mailing Address - Country:US
Mailing Address - Phone:574-273-9313
Mailing Address - Fax:574-273-6261
Practice Address - Street 1:209 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-8048
Practice Address - Country:US
Practice Address - Phone:574-246-1000
Practice Address - Fax:574-246-4000
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000394A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200217280Medicaid