Provider Demographics
NPI:1396344222
Name:ANDERSON, MARY LYNN (LVN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LYNN
Other - Last Name:PETTERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:311 OCEANSIDE BLVD SPC 49
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-5130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:311 OCEANSIDE BLVD SPC 49
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-5130
Practice Address - Country:US
Practice Address - Phone:760-803-0296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN205279164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse