Provider Demographics
NPI:1093014839
Name:ANDERSON, TERRYE ANNETTE (NP)
Entity type:Individual
Prefix:
First Name:TERRYE
Middle Name:ANNETTE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 N GLENWOOD AVE
Mailing Address - Street 2:RIALTO
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-3989
Mailing Address - Country:US
Mailing Address - Phone:909-874-6899
Mailing Address - Fax:
Practice Address - Street 1:1180 N GLENWOOD AVE
Practice Address - Street 2:RIALTO
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-3989
Practice Address - Country:US
Practice Address - Phone:909-874-6899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-18
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19849363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily