Provider Demographics
NPI:1487701322
Name:ANDERSON, CONNIE J (FNP)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:J
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 1:2821 NE 58TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-3473
Mailing Address - Country:US
Mailing Address - Phone:503-460-0405
Mailing Address - Fax:503-460-0434
Practice Address - Street 1:2821 NE 58TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3473
Practice Address - Country:US
Practice Address - Phone:503-460-0405
Practice Address - Fax:503-460-0434
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200650159NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily