Provider Demographics
NPI:1356956403
Name:ANDERSON, GEORGINA EVELYN
Entity type:Individual
Prefix:
First Name:GEORGINA
Middle Name:EVELYN
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 1:3930 CRYSTAL LAKE DR APT 309
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-1221
Mailing Address - Country:US
Mailing Address - Phone:954-464-5460
Mailing Address - Fax:
Practice Address - Street 1:3000 BAYVIEW DR STE 100
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1772
Practice Address - Country:US
Practice Address - Phone:954-567-1332
Practice Address - Fax:561-537-2721
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11008198363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily