Provider Demographics
NPI:1568579860
Name:ANDERSON, CONDRA M (FNP)
Entity Type:Individual
Prefix:MS
First Name:CONDRA
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1806 N ALCO AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-3818
Mailing Address - Country:US
Mailing Address - Phone:660-582-8807
Mailing Address - Fax:
Practice Address - Street 1:26136 US HIGHWAY 59
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:MO
Practice Address - Zip Code:64446-8155
Practice Address - Country:US
Practice Address - Phone:660-686-2211
Practice Address - Fax:660-686-2618
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO056910363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO429057508Medicaid
MO10001788900OtherCOMMUNITY HEALTH PLAN
MO540492501Medicaid