Provider Demographics
NPI:1467893685
Name:SANDERSON, MICHELLE RENAE (RN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENAE
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:RENAE
Other - Last Name:FRENG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:454 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MN
Mailing Address - Zip Code:55972-1546
Mailing Address - Country:US
Mailing Address - Phone:507-269-1455
Mailing Address - Fax:
Practice Address - Street 1:454 E 15TH ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MN
Practice Address - Zip Code:55972-1546
Practice Address - Country:US
Practice Address - Phone:507-269-1455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR193111-0163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse