Provider Demographics
NPI:1053668657
Name:SANDER, JENNIFER A (RN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:A
Last Name:SANDER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:KIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2128 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14207-1910
Mailing Address - Country:US
Mailing Address - Phone:716-874-4500
Mailing Address - Fax:716-874-8145
Practice Address - Street 1:2128 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14207-1910
Practice Address - Country:US
Practice Address - Phone:716-874-4500
Practice Address - Fax:716-874-8145
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY455229-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01465154Medicaid