Basic Information
| Provider Information | |||||||||
| NPI: | 1154080430 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | JO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1345 UNITY PL STE 345 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479055761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654465111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1345 UNITY PL STE 345 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479055761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654465111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2021 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71011925A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 71011925A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.