Provider Demographics
NPI:1316161425
Name:ANDERSON, MARIA ANTONETTE
Entity type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:ANTONETTE
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 1:147 NEWTON RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-3527
Mailing Address - Country:US
Mailing Address - Phone:770-306-2294
Mailing Address - Fax:770-964-5385
Practice Address - Street 1:147 NEWTON RD
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-3527
Practice Address - Country:US
Practice Address - Phone:770-306-2294
Practice Address - Fax:770-964-5385
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator