Basic Information
| Provider Information | |||||||||
| NPI: | 1063756211 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | WILLARD | ||||||||
| MiddleName: | MARVIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1559 | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371331559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152782241 | ||||||||
| FaxNumber: | 6152067587 | ||||||||
| Practice Location | |||||||||
| Address1: | 3686 US HIGHWAY 331 S | ||||||||
| Address2: | |||||||||
| City: | DEFUNIAK SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324358463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508928045 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2012 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 9348879 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.