Provider Demographics
NPI:1821277641
Name:ANDERSON, KATHRYN D (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:D
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 W BELLA DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46953-5250
Mailing Address - Country:US
Mailing Address - Phone:765-651-6637
Mailing Address - Fax:765-651-6639
Practice Address - Street 1:1411 W BELLA DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-5250
Practice Address - Country:US
Practice Address - Phone:765-651-6637
Practice Address - Fax:765-651-6639
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002537A363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200882340Medicaid
000000542597OtherANTHEM, BLUE CROSS BLUE SHIELD
000000542597OtherANTHEM, BLUE CROSS BLUE SHIELD