Provider Demographics
NPI:1063885606
Name:ANDERSON BOTT, JANET PATRICIA (MSC)
Entity type:Individual
Prefix:MRS
First Name:JANET
Middle Name:PATRICIA
Last Name:ANDERSON BOTT
Suffix:
Gender:F
Credentials:MSC
Other - Prefix:MISS
Other - First Name:JANET
Other - Middle Name:PATRICIA
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSC
Mailing Address - Street 1:88 LOUIS AVE
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-1239
Mailing Address - Country:US
Mailing Address - Phone:516-451-0727
Mailing Address - Fax:
Practice Address - Street 1:88 LOUIS AVE
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-1239
Practice Address - Country:US
Practice Address - Phone:516-451-0727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY95890OtherSTATE CERTIFICATION 2