Provider Demographics
NPI:1902478811
Name:ANDERSON, JOAN MARIE
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:
Other - Last Name:WALTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1320 19TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-2752
Mailing Address - Country:US
Mailing Address - Phone:563-243-5633
Mailing Address - Fax:563-243-9567
Practice Address - Street 1:1320 19TH AVE NW
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-2752
Practice Address - Country:US
Practice Address - Phone:563-243-5633
Practice Address - Fax:563-243-9567
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG164271363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health