Provider Demographics
NPI:1588635874
Name:ANDERSON, MARY LOU (NP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOU
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E FONTANERO ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-7529
Mailing Address - Country:US
Mailing Address - Phone:719-327-5660
Mailing Address - Fax:719-866-6239
Practice Address - Street 1:320 E FONTANERO ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-7529
Practice Address - Country:US
Practice Address - Phone:719-327-5660
Practice Address - Fax:719-866-6239
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO113498363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO113498Medicare UPIN