Provider Demographics
NPI:1396151197
Name:ANDERSON, BRENDA ANN (MSN FNP)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:ANN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MSN FNP
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:ANN
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSN FNP
Mailing Address - Street 1:2709 CURDES AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-2807
Mailing Address - Country:US
Mailing Address - Phone:260-494-2192
Mailing Address - Fax:
Practice Address - Street 1:6279 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-7641
Practice Address - Country:US
Practice Address - Phone:260-494-2192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28155137A163W00000X
IN71005015A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse