Provider Demographics
NPI:1598865347
Name:ANDERSON, MARY ELLEN (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
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 1:104 RAINTREE PL
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-2244
Mailing Address - Country:US
Mailing Address - Phone:818-462-0990
Mailing Address - Fax:
Practice Address - Street 1:1201 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-9811
Practice Address - Country:US
Practice Address - Phone:270-417-5911
Practice Address - Fax:270-417-6497
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4690P363L00000X
KY3004690363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000845568OtherANTHEM
KYP01351973OtherRR MEDICARE
KY7100235010Medicaid
KYK061312Medicare UPIN