Provider Demographics
NPI:1376052902
Name:ANDERSON, AUDREY LOUISE (MSN RN FNP-BC)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:LOUISE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MSN RN FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 DEER VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:MI
Mailing Address - Zip Code:48442-1561
Mailing Address - Country:US
Mailing Address - Phone:248-894-2825
Mailing Address - Fax:
Practice Address - Street 1:26677 W 12 MILE RD STE 166
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1514
Practice Address - Country:US
Practice Address - Phone:313-306-2023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704225111363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily