Provider Demographics
NPI:1346475399
Name:ANDERSON, MARY ANGELINE (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANGELINE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 W BUSCH BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-7603
Mailing Address - Country:US
Mailing Address - Phone:813-684-2229
Mailing Address - Fax:813-413-8516
Practice Address - Street 1:1513 W BUSCH BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-7603
Practice Address - Country:US
Practice Address - Phone:813-684-2229
Practice Address - Fax:813-413-8516
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9217012363LW0102X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health