Provider Demographics
NPI:1366871634
Name:ANDERSEN, SALLY (FNP-BC, APNP)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:FNP-BC, APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W5505 MILE LONG DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-5220
Mailing Address - Country:US
Mailing Address - Phone:920-851-6114
Mailing Address - Fax:
Practice Address - Street 1:W6981 PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:WI
Practice Address - Zip Code:54942-8034
Practice Address - Country:US
Practice Address - Phone:920-882-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5543-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily