Provider Demographics
NPI:1588467187
Name:ANDERSON, WENDY SUE (MM 39716, MA 75645)
Entity type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:SUE
Last Name:ANDERSON
Suffix:
Gender:
Credentials:MM 39716, MA 75645
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 W US HIGHWAY 90 STE 101
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-4744
Mailing Address - Country:US
Mailing Address - Phone:727-623-6311
Mailing Address - Fax:
Practice Address - Street 1:3101 W US HIGHWAY 90 STE 101
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4744
Practice Address - Country:US
Practice Address - Phone:727-623-6311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-29
Last Update Date:2025-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL75645225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist