Provider Demographics
NPI:1710067483
Name:ANDERSON, BRENDA (NP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
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 1:611 W. PARK ST.
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6941
Mailing Address - Fax:
Practice Address - Street 1:1818 E. WINDSOR ROAD
Practice Address - Street 2:ADULT MEDICINE/GERIATRICS
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802
Practice Address - Country:US
Practice Address - Phone:217-255-9946
Practice Address - Fax:217-255-9650
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001373363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P21203Medicare UPIN
IL6447860006Medicare NSC
ILP21203Medicare UPIN
ILIL3270380Medicare PIN