Provider Demographics
NPI:1013683747
Name:ANDERSEN, ANNALIESE
Entity Type:Individual
Prefix:
First Name:ANNALIESE
Middle Name:
Last Name:ANDERSEN
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:PO BOX 686
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:TX
Mailing Address - Zip Code:78124-0686
Mailing Address - Country:US
Mailing Address - Phone:830-305-9290
Mailing Address - Fax:
Practice Address - Street 1:388 STALLION LN
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:TX
Practice Address - Zip Code:78124-3014
Practice Address - Country:US
Practice Address - Phone:830-305-9290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-22
Last Update Date:2021-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer