Provider Demographics
NPI:1427044288
Name:IVY SANDERSON, DEBORA (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:DEBORA
Middle Name:
Last Name:IVY SANDERSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 UNICORN LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-0102
Mailing Address - Country:US
Mailing Address - Phone:940-383-1578
Mailing Address - Fax:940-382-0333
Practice Address - Street 1:1300 ENTERPRISE RD.
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801
Practice Address - Country:US
Practice Address - Phone:575-835-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP114027363LF0000X
NM65006363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ69347Medicare UPIN