Provider Demographics
NPI:1326264599
Name:ANDERSON, STEVEN MARK (LPN)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:MARK
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 TIFFANY ST
Mailing Address - Street 2:
Mailing Address - City:BOYCEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54725-9543
Mailing Address - Country:US
Mailing Address - Phone:715-643-2208
Mailing Address - Fax:
Practice Address - Street 1:1511 TIFFANY ST
Practice Address - Street 2:
Practice Address - City:BOYCEVILLE
Practice Address - State:WI
Practice Address - Zip Code:54725-9543
Practice Address - Country:US
Practice Address - Phone:715-643-2208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI304080164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35015700Medicaid