Provider Demographics
NPI:1598044604
Name:ANDERSON, TINA (LPN)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 S COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-5652
Mailing Address - Country:US
Mailing Address - Phone:937-371-5148
Mailing Address - Fax:
Practice Address - Street 1:495 S COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-5652
Practice Address - Country:US
Practice Address - Phone:937-371-5148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-07
Last Update Date:2011-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.133740-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse