Provider Demographics
NPI:1275998734
Name:ANDERSON, DAISY
Entity Type:Individual
Prefix:
First Name:DAISY
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 1:14315 104TH ST
Mailing Address - Street 2:
Mailing Address - City:COAL VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61240-9747
Mailing Address - Country:US
Mailing Address - Phone:309-235-1580
Mailing Address - Fax:309-787-2496
Practice Address - Street 1:14315 104TH ST
Practice Address - Street 2:
Practice Address - City:COAL VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61240-9747
Practice Address - Country:US
Practice Address - Phone:309-235-1580
Practice Address - Fax:309-787-2496
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter