Provider Demographics
NPI:1679233977
Name:ANDERSON, KERRY GRACE
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:GRACE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:215-871-6702
Practice Address - Street 1:401 YOUNG AVE STE 260A
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3130
Practice Address - Country:US
Practice Address - Phone:856-291-8756
Practice Address - Fax:856-291-8750
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
25MP00745700363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant