Basic Information
| Provider Information | |||||||||
| NPI: | 1598865347 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELLEN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 RAINTREE PL | ||||||||
| Address2: | |||||||||
| City: | GLASGOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421412244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8184620990 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1201 PLEASANT VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423039811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704175911 | ||||||||
| FaxNumber: | 2704176497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 09/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4690P | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 3004690 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 000000845568 | 01 | KY | ANTHEM | OTHER | P01351973 | 01 | KY | RR MEDICARE | OTHER | 7100235010 | 05 | KY | MEDICAID |