Provider Demographics
NPI:1417689324
Name:SANDERS, CHARLENE AMANDA
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:AMANDA
Last Name:SANDERS
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 1:122 VINELAND PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:VINE GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:40175-8447
Mailing Address - Country:US
Mailing Address - Phone:870-275-0700
Mailing Address - Fax:
Practice Address - Street 1:325 W DIXIE AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-1757
Practice Address - Country:US
Practice Address - Phone:870-275-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAPRN3017999363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care