Provider Demographics
NPI:1376433383
Name:ANDERSON, KODA DEANN
Entity type:Individual
Prefix:
First Name:KODA
Middle Name:DEANN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4029 AVENUE N
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76105-3537
Mailing Address - Country:US
Mailing Address - Phone:682-847-3303
Mailing Address - Fax:
Practice Address - Street 1:4029 AVENUE N
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76105-3537
Practice Address - Country:US
Practice Address - Phone:682-847-3303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-09
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant