Provider Demographics
NPI:1023342144
Name:ANDERSON, TAKELA NAQUAY (FNP)
Entity type:Individual
Prefix:
First Name:TAKELA
Middle Name:NAQUAY
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8108 BROAD RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:BROWNS SUMMIT
Mailing Address - State:NC
Mailing Address - Zip Code:27214-9848
Mailing Address - Country:US
Mailing Address - Phone:336-253-4365
Mailing Address - Fax:
Practice Address - Street 1:4002 SPRING GARDEN ST
Practice Address - Street 2:STE C
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-1683
Practice Address - Country:US
Practice Address - Phone:336-553-0793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-22
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004483363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2594771Medicare PIN