Provider Demographics
NPI:1417765579
Name:ANDERSON, MEGAN (NUTRITIONIST)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NUTRITIONIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 N GULKANA CT
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-6156
Mailing Address - Country:US
Mailing Address - Phone:715-797-7187
Mailing Address - Fax:
Practice Address - Street 1:5000 E SHENNUM DR # 1
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7718
Practice Address - Country:US
Practice Address - Phone:907-373-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK233304133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist