Provider Demographics
NPI:1619626652
Name:ANDERSON, KASSANDRA ELIZABETH (FNP-C)
Entity type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:ELIZABETH
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 MAYE ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:MN
Mailing Address - Zip Code:56178-9490
Mailing Address - Country:US
Mailing Address - Phone:605-838-7118
Mailing Address - Fax:
Practice Address - Street 1:240 WILLOW ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:MN
Practice Address - Zip Code:56178-1201
Practice Address - Country:US
Practice Address - Phone:507-247-5521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9047363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily