Basic Information
| Provider Information | |||||||||
| NPI: | 1255095253 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | FIELDING | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11936 MAGNOLIA BLVD APT 411 | ||||||||
| Address2: | |||||||||
| City: | VALLEY VILLAGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 916074453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182874238 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8142 SUNLAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SUN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185828832 | ||||||||
| FaxNumber: | 8185828836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2021 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.