Provider Demographics
NPI:1386964443
Name:ANDERSON, THERESA J (AP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 JACKSON AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:CAPE CANAVERAL
Mailing Address - State:FL
Mailing Address - Zip Code:32920-2366
Mailing Address - Country:US
Mailing Address - Phone:407-432-9193
Mailing Address - Fax:
Practice Address - Street 1:2425 N COURTENAY PKWY UNIT 4
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4100
Practice Address - Country:US
Practice Address - Phone:407-432-9193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP4016171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist