Provider Demographics
NPI:1861028540
Name:ANDERSON, VERDELLE
Entity Type:Individual
Prefix:
First Name:VERDELLE
Middle Name:
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 1:14810 LA MESA RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-8639
Mailing Address - Country:US
Mailing Address - Phone:760-951-0510
Mailing Address - Fax:
Practice Address - Street 1:14810 LA MESA RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-8639
Practice Address - Country:US
Practice Address - Phone:760-951-0510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider