Provider Demographics
NPI:1255408894
Name:ANZALONE, ANDREA BARBERA (WHCNPC)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:BARBERA
Last Name:ANZALONE
Suffix:
Gender:F
Credentials:WHCNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13307 MIAMI LN
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-4701
Mailing Address - Country:US
Mailing Address - Phone:208-455-7000
Mailing Address - Fax:208-455-7722
Practice Address - Street 1:13307 MIAMI LN
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-4701
Practice Address - Country:US
Practice Address - Phone:208-455-7000
Practice Address - Fax:208-455-7722
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4554318796363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1255408894Medicaid