Provider Demographics
NPI:1013349778
Name:ANDERSON, CAITLYN MARIE
Entity type:Individual
Prefix:
First Name:CAITLYN
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAITLYN
Other - Middle Name:MARIE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1041 N 400 W
Mailing Address - Street 2:
Mailing Address - City:BLANDING
Mailing Address - State:UT
Mailing Address - Zip Code:84511-3420
Mailing Address - Country:US
Mailing Address - Phone:208-221-0505
Mailing Address - Fax:
Practice Address - Street 1:5150 S WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4506
Practice Address - Country:US
Practice Address - Phone:801-337-0067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program