Basic Information
| Provider Information | |||||||||
| NPI: | 1114946829 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSEN | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | TIGUE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MURRAY | ||||||||
| OtherFirstName: | KATHLEEN | ||||||||
| OtherMiddleName: | T | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4512 KIRKWOOD HWY | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198085123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3029990137 | ||||||||
| FaxNumber: | 3029991042 | ||||||||
| Practice Location | |||||||||
| Address1: | 4512 KIRKWOOD HIGHWAY | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 19808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3029990137 | ||||||||
| FaxNumber: | 3029991042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 10/16/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | LG0000293 | DE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0001127242 | 05 | DE | MEDICAID |