Provider Demographics
NPI:1134969116
Name:ANDERSON, KATHLEEN MARIE
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
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 1:612 MOSS WAY
Mailing Address - Street 2:
Mailing Address - City:PALISADE
Mailing Address - State:CO
Mailing Address - Zip Code:81526-9238
Mailing Address - Country:US
Mailing Address - Phone:970-270-3694
Mailing Address - Fax:
Practice Address - Street 1:743 HORIZON CT STE 100
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-8715
Practice Address - Country:US
Practice Address - Phone:970-241-7600
Practice Address - Fax:970-245-9094
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.0199454390200000X
COAPN.1000381-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program