1114946829 NPI number — KATHLEEN TIGUE ANDERSEN APN

Table of content: KATHLEEN TIGUE ANDERSEN APN (NPI 1114946829)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114946829 NPI number — KATHLEEN TIGUE ANDERSEN APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSEN
Provider First Name:
KATHLEEN
Provider Middle Name:
TIGUE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MURRAY
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
T
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114946829
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4512 KIRKWOOD HWY
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19808-5123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-999-0137
Provider Business Mailing Address Fax Number:
302-999-1042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4512 KIRKWOOD HIGHWAY
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-999-0137
Provider Business Practice Location Address Fax Number:
302-999-1042
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  LG0000293 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0001127242 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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