Provider Demographics
NPI:1922773241
Name:ANDERSON, VICTORIA A (CNA;( CCMA))
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CNA;( CCMA)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 N LUETT AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-2407
Mailing Address - Country:US
Mailing Address - Phone:317-679-7188
Mailing Address - Fax:
Practice Address - Street 1:1387 N SHADELAND AVE STE E
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3605
Practice Address - Country:US
Practice Address - Phone:317-361-6988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN21-015355-1374U00000X
IN253Z00000X, 343900000X, 347C00000X, 3747A0650X
IN000657374U00000X
IN15D2275815291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
No253Z00000XAgenciesIn Home Supportive Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN210153551Medicaid