Provider Demographics
NPI:1508412479
Name:ANDERSON, AMY ROSE (LVN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ROSE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DYSART UNIFIED SCHOOL DISTRICT #89
Mailing Address - Street 2:15802 N PARKVIEW PLACE
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374
Mailing Address - Country:US
Mailing Address - Phone:623-876-7923
Mailing Address - Fax:
Practice Address - Street 1:15802 N PARKVIEW PL
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7466
Practice Address - Country:US
Practice Address - Phone:623-523-8750
Practice Address - Fax:623-523-8761
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX329429164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse