Provider Demographics
NPI:1578078341
Name:SANDERSON, DEIDRI
Entity Type:Individual
Prefix:
First Name:DEIDRI
Middle Name:
Last Name:SANDERSON
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:PO BOX 1602
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27323-1602
Mailing Address - Country:US
Mailing Address - Phone:336-587-3631
Mailing Address - Fax:
Practice Address - Street 1:1110 7TH AVE
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:WI
Practice Address - Zip Code:54829-9138
Practice Address - Country:US
Practice Address - Phone:715-822-2741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-02
Last Update Date:2017-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCJ6P7L8D8246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy