Provider Demographics
NPI:1306846803
Name:SANDERS, DEIDRA HENLEY (APRN)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:HENLEY
Last Name:SANDERS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9800 SHELBYVILLE RD
Mailing Address - Street 2:SUITE #220
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-2992
Mailing Address - Country:US
Mailing Address - Phone:502-429-8585
Mailing Address - Fax:502-753-0889
Practice Address - Street 1:9800 SHELBYVILLE RD
Practice Address - Street 2:SUITE #220
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-2992
Practice Address - Country:US
Practice Address - Phone:502-429-8585
Practice Address - Fax:502-429-6157
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2338P363L00000X
IN71000277A363L00000X
KY3002338363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1050107OtherPASSPORT PROVIDER NUMBER
KY1050107OtherPASSPORT PROVIDER NUMBER
KYS50391Medicare UPIN
IN181540DMedicare ID - Type UnspecifiedPROVIDER NUMBER