Provider Demographics
NPI:1245648914
Name:ANDERSON, MARY LOU
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
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 1:7171 S CHEROKEE TRL
Mailing Address - Street 2:#1911
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80016-2287
Mailing Address - Country:US
Mailing Address - Phone:303-617-8058
Mailing Address - Fax:
Practice Address - Street 1:7171 S CHEROKEE TRL
Practice Address - Street 2:#1911
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80016-2287
Practice Address - Country:US
Practice Address - Phone:303-617-8058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO94735163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical