Provider Demographics
NPI:1598079675
Name:SANDERSON, AMY MELINDA (APRN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MELINDA
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4071 TATES CREEK CENTRE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-3062
Mailing Address - Country:US
Mailing Address - Phone:859-625-0900
Mailing Address - Fax:859-625-0995
Practice Address - Street 1:789 EASTERN BYP
Practice Address - Street 2:SUITE 14
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2415
Practice Address - Country:US
Practice Address - Phone:859-625-0900
Practice Address - Fax:859-625-0995
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1112888163W00000X
KY3006515363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100136150OtherMEDICAID
KYP400024193Medicare PIN
KYK013333Medicare PIN
KY9065Medicare PIN