Provider Demographics
NPI:1255109831
Name:ANDERSON, MICHELE RENEE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:RENEE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10098 CHERRY AVE
Mailing Address - Street 2:
Mailing Address - City:CHERRY VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92223-4514
Mailing Address - Country:US
Mailing Address - Phone:760-574-9464
Mailing Address - Fax:
Practice Address - Street 1:10098 CHERRY AVE
Practice Address - Street 2:
Practice Address - City:CHERRY VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92223-4514
Practice Address - Country:US
Practice Address - Phone:760-574-9464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95028156363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health