Provider Demographics
NPI:1780808063
Name:ANDERSON, KATHLEEN MAURA (RN)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MAURA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 THEATER COLONY WAY
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-2035
Mailing Address - Country:US
Mailing Address - Phone:508-265-1398
Mailing Address - Fax:
Practice Address - Street 1:5 THEATER COLONY WAY
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2035
Practice Address - Country:US
Practice Address - Phone:508-265-1398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA230746163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0706248Medicaid