Provider Demographics
NPI:1528417631
Name:ANDERSON, DEBBIE
Entity Type:Individual
Prefix:
First Name:DEBBIE
Middle Name:
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 1:330 N STATE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:DESLOGE
Mailing Address - State:MO
Mailing Address - Zip Code:63601-3052
Mailing Address - Country:US
Mailing Address - Phone:573-431-2829
Mailing Address - Fax:573-431-2443
Practice Address - Street 1:330 N STATE ST
Practice Address - Street 2:SUITE C
Practice Address - City:DESLOGE
Practice Address - State:MO
Practice Address - Zip Code:63601-3052
Practice Address - Country:US
Practice Address - Phone:573-431-2829
Practice Address - Fax:573-431-5177
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015032920363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily