Provider Demographics
NPI:1275089666
Name:SANDERSON, DIAN
Entity Type:Individual
Prefix:MRS
First Name:DIAN
Middle Name:
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 W 204TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-4008
Mailing Address - Country:US
Mailing Address - Phone:718-336-5123
Mailing Address - Fax:718-336-5137
Practice Address - Street 1:2960 OCEAN AVE
Practice Address - Street 2:6TH FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3202
Practice Address - Country:US
Practice Address - Phone:718-336-5123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340966-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily