Provider Demographics
NPI:1356049712
Name:ANDERSON, CARLA
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:
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 1:5278 SE CHANNEL DR
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-3327
Mailing Address - Country:US
Mailing Address - Phone:772-200-7849
Mailing Address - Fax:
Practice Address - Street 1:5278 SE CHANNEL DR
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-3327
Practice Address - Country:US
Practice Address - Phone:772-200-7849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246R00000X
FL20-312757163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No246R00000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20-312757OtherIV THERAPY CERTIFICATION