Provider Demographics
NPI:1821306424
Name:FEDOTOVA, ANNA VLADIMIROVNA
Entity Type:Individual
Prefix:DR
First Name:ANNA
Middle Name:VLADIMIROVNA
Last Name:FEDOTOVA
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 1:2050A 2ND ST SE
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND AFB
Mailing Address - State:NM
Mailing Address - Zip Code:87117-5522
Mailing Address - Country:US
Mailing Address - Phone:505-846-3305
Mailing Address - Fax:
Practice Address - Street 1:2050 A SECOND STREET SE
Practice Address - Street 2:
Practice Address - City:KIRTLAND AFB
Practice Address - State:NM
Practice Address - Zip Code:87117-5546
Practice Address - Country:US
Practice Address - Phone:505-846-3305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6933103T00000X
103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103T00000XBehavioral Health & Social Service ProvidersPsychologist