| Doctor Name: | CARLY JO ANDERSON |
| NPI Number: | 1093192833 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | MA |
| License Number: | |
| Business Practice Address: | 16180 Hastings Ave Se Suite 205 Prior Lake, MN - 553729227 |
| Business Phone Number: | 9524434600 |
| Business Fax Number: | 9524404601 |
| Mailing Address: | 16180 Hastings Ave Se, Suite 205 PRIOR LAKE |
| State: | MN |
| Postal Code: | 553729227 |
| Phone Number: | 9524434600 |
| Fax Number: | 9524404601 |
| NPI Enumeration Date: | 04/30/2015 |
| NPI Last Update Date: | 04/30/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 390200000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Student, Health Care |
| Taxonomy Classification: | Student in an Organized Health Care Education/Training Program |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care. |