Provider Demographics
NPI:1528577640
Name:ANDERSON, PETRONA FANTELLA
Entity Type:Individual
Prefix:
First Name:PETRONA
Middle Name:FANTELLA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PETRONA
Other - Middle Name:FANTELLA
Other - Last Name:ANDERSON-FORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:468 BRUNSWICK CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-2461
Mailing Address - Country:US
Mailing Address - Phone:706-951-4498
Mailing Address - Fax:
Practice Address - Street 1:5005 NORTH PIEDRAS STREET
Practice Address - Street 2:WBAMC
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79920-5001
Practice Address - Country:US
Practice Address - Phone:915-569-4890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009066101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional