Provider Demographics
NPI:1891771754
Name:ANDERSON, REGINA (FNP)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 JEFFERSON AVE
Mailing Address - Street 2:5TH FLOOR ADAMS PAVILION
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2807
Mailing Address - Country:US
Mailing Address - Phone:901-515-4529
Mailing Address - Fax:901-272-0292
Practice Address - Street 1:1000 HAYNES ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38114-3374
Practice Address - Country:US
Practice Address - Phone:901-515-5200
Practice Address - Fax:901-323-6807
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNRN 89402363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3903799Medicaid
TN3903799Medicaid
TN3903799Medicare ID - Type Unspecified