Provider Demographics
NPI:1174758312
Name:ANDERSON, NANCY PORTER (LAC)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:PORTER
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5252 BALBOA AVENUE #1002
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117
Mailing Address - Country:US
Mailing Address - Phone:619-921-7733
Mailing Address - Fax:858-277-2183
Practice Address - Street 1:5252 BALBOA AVE STE 1002
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-7011
Practice Address - Country:US
Practice Address - Phone:619-921-7733
Practice Address - Fax:858-277-2183
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-18
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA6968171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist