Provider Demographics
NPI:1861272569
Name:ANDERSON, MARYANN (ANP ADULT NURSE PRAC)
Entity type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:ANP ADULT NURSE PRAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 NIAGARA STREET, UPPER
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120
Mailing Address - Country:US
Mailing Address - Phone:716-289-0068
Mailing Address - Fax:
Practice Address - Street 1:HOST HEALTHCARE
Practice Address - Street 2:7676 HAZARD CENTER DRIVE #500
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108
Practice Address - Country:US
Practice Address - Phone:800-585-1299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309005363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty