Provider Demographics
NPI:1811238645
Name:ANDERSON, ANGELICA ELIZABETH (PT)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:ELIZABETH
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ANGELICA
Other - Middle Name:ELIZABETH
Other - Last Name:FLYNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1010 S 336TH ST
Mailing Address - Street 2:SUITE 112
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6385
Mailing Address - Country:US
Mailing Address - Phone:253-661-0041
Mailing Address - Fax:253-661-0772
Practice Address - Street 1:1010 S 336TH ST
Practice Address - Street 2:SUITE 112
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6385
Practice Address - Country:US
Practice Address - Phone:253-661-0041
Practice Address - Fax:253-661-0772
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-04
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60329481225100000X
AZ10804225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ10804OtherLICENSE
WAG8921300Medicare UPIN