Provider Demographics
NPI:1073503322
Name:SANDER, MARY SUSAN (CNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SUSAN
Last Name:SANDER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:SUSAN
Other - Last Name:TELLONI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:2726 FULTON DR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3506
Mailing Address - Country:US
Mailing Address - Phone:330-455-5011
Mailing Address - Fax:330-588-7127
Practice Address - Street 1:2726 FULTON DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3506
Practice Address - Country:US
Practice Address - Phone:330-455-5011
Practice Address - Fax:330-588-7127
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-05340363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2179664Medicaid
OHP00341076OtherMEDICARE RAILROAD
OH000000492313OtherANTHEM
OH1073503322OtherHOMETOWN
OH341773267GOtherAULTCARE
OHP00341076OtherMEDICARE RAILROAD