Provider Demographics
NPI:1326093493
Name:TATE, SANDRA (APN)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:TATE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-2401
Mailing Address - Fax:618-724-4628
Practice Address - Street 1:3412 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-6477
Practice Address - Country:US
Practice Address - Phone:618-292-9999
Practice Address - Fax:618-551-2757
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005279363LP0808X
IL041290556364SP0808X
IL277000849364SP0808X, 364SP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCG2264OtherRR GROUP NUMBER
IL207988OtherGROUP
ILP00220754OtherRR MEDICARE NUMBER
ILK15498Medicare ID - Type UnspecifiedMEDICARE
ILCG2264OtherRR GROUP NUMBER