Provider Demographics
NPI:1083420020
Name:ANDERSON, KATHLEEN LYNN
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4081 INDIAN BEND RD
Mailing Address - Street 2:
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-6521
Mailing Address - Country:US
Mailing Address - Phone:928-666-1337
Mailing Address - Fax:
Practice Address - Street 1:4081 INDIAN BEND RD
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-6521
Practice Address - Country:US
Practice Address - Phone:928-666-1337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-04
Last Update Date:2024-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral