Provider Demographics
NPI:1023202512
Name:SANDERSON, ROSALEA NELLIE (IDC)
Entity Type:Individual
Prefix:
First Name:ROSALEA
Middle Name:NELLIE
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 455, BOX 156
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:GUAM
Mailing Address - Zip Code:AP
Mailing Address - Country:US
Mailing Address - Phone:671-339-7118
Mailing Address - Fax:671-339-5002
Practice Address - Street 1:PSC 455, BOX 156
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:GUAM
Practice Address - Zip Code:AP
Practice Address - Country:US
Practice Address - Phone:671-339-7118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman