Provider Demographics
NPI:1871563536
Name:ANDERSON, GRETCHEN L (RN, CS, MS(N),FNP)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RN, CS, MS(N),FNP
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Mailing Address - Street 1:3917 WEST RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-2275
Mailing Address - Country:US
Mailing Address - Phone:505-661-8900
Mailing Address - Fax:505-661-8961
Practice Address - Street 1:3917 WEST RD
Practice Address - Street 2:SUITE A
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-2275
Practice Address - Country:US
Practice Address - Phone:505-661-8900
Practice Address - Fax:505-661-8961
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2012-01-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO102429163WG0000X
NMCNP-01819363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO429664626Medicaid
MO429664626Medicaid
S93522Medicare UPIN