Provider Demographics
NPI:1962975490
Name:ANDERSON, DONESHA ALISSA
Entity type:Individual
Prefix:
First Name:DONESHA
Middle Name:ALISSA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:643 ALEXANDER ST
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-6007
Mailing Address - Country:US
Mailing Address - Phone:214-802-9155
Mailing Address - Fax:
Practice Address - Street 1:643 ALEXANDER ST
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-6007
Practice Address - Country:US
Practice Address - Phone:214-802-9155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX319419164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse