Provider Demographics
NPI:1437758067
Name:ANDERSON, MARLA LISTER
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:LISTER
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 1:43 N TERRACE N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-3815
Mailing Address - Country:US
Mailing Address - Phone:701-388-3052
Mailing Address - Fax:
Practice Address - Street 1:43 N TERRACE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3815
Practice Address - Country:US
Practice Address - Phone:701-388-3052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-24
Last Update Date:2020-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant