Provider Demographics
NPI:1548609431
Name:ANDERSON, BIANCA MARIA (MS, RD)
Entity Type:Individual
Prefix:MS
First Name:BIANCA
Middle Name:MARIA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:BIANCA
Other - Middle Name:MARIA
Other - Last Name:TERAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:PAYER CREDENTIALING
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-213-6235
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:1200 N BEAVER ST
Practice Address - Street 2:PAYER CREDENTIALING
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3118
Practice Address - Country:US
Practice Address - Phone:928-773-2054
Practice Address - Fax:928-773-2286
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1031781133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ826172Medicaid
AZ826172Medicaid
AZZ198935Medicare PIN