Provider Demographics
NPI:1174973879
Name:ANDERSON, MICHEL (FNP)
Entity type:Individual
Prefix:
First Name:MICHEL
Middle Name:
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:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1422 S SAM HOUSTON BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MO
Practice Address - Zip Code:65483-2130
Practice Address - Country:US
Practice Address - Phone:417-967-4445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016018333363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
MOPENDINGMedicare PIN