Provider Demographics
NPI:1942589569
Name:ANDERSSON, AMY MARIKO (MA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIKO
Last Name:ANDERSSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 N MURRAY ST
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-5528
Mailing Address - Country:US
Mailing Address - Phone:951-849-8812
Mailing Address - Fax:951-755-8915
Practice Address - Street 1:245 N MURRAY ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-5528
Practice Address - Country:US
Practice Address - Phone:951-849-8812
Practice Address - Fax:951-755-8915
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor