Provider Demographics
NPI:1063756211
Name:ANDERSON, WILLARD MARVIN III (PMHNP)
Entity type:Individual
Prefix:
First Name:WILLARD
Middle Name:MARVIN
Last Name:ANDERSON
Suffix:III
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1956 BARKER CAMP RD
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:TN
Mailing Address - Zip Code:37327-5939
Mailing Address - Country:US
Mailing Address - Phone:615-568-5529
Mailing Address - Fax:850-681-6003
Practice Address - Street 1:459 GRACE AVE STE 100
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2757
Practice Address - Country:US
Practice Address - Phone:615-568-5529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-11
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9348879363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health