Provider Demographics
NPI:1467531921
Name:ANDERSEN, KATHERINE (DOM)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 SOUTH RIO GRANDE AVE.
Mailing Address - Street 2:SUITE B
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410
Mailing Address - Country:US
Mailing Address - Phone:505-334-2008
Mailing Address - Fax:505-334-5515
Practice Address - Street 1:606 SOUTH RIO GRANDE AVE.
Practice Address - Street 2:SUITE B
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410
Practice Address - Country:US
Practice Address - Phone:505-334-2008
Practice Address - Fax:505-334-5515
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM208171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM01R303OtherBLUE CROSS