Basic Information
| Provider Information | |||||||||
| NPI: | 1811238645 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | ANGELICA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FLYNN | ||||||||
| OtherFirstName: | ANGELICA | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1010 S 336TH ST | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980036385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536610041 | ||||||||
| FaxNumber: | 2536610772 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 S 336TH ST | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980036385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536610041 | ||||||||
| FaxNumber: | 2536610772 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2013 | ||||||||
| LastUpdateDate: | 06/14/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT60329481 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 10804 | AZ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 10804 | 01 | AZ | LICENSE | OTHER |