Provider Demographics
NPI:1912271818
Name:ANDERSON, MARK D (LPN)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 WOOD PARK DR
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-2651
Mailing Address - Country:US
Mailing Address - Phone:330-688-2381
Mailing Address - Fax:
Practice Address - Street 1:4210 WOOD PARK DR
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-2651
Practice Address - Country:US
Practice Address - Phone:330-688-2381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH145709164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse