Provider Demographics
NPI:1629150669
Name:LEADERS, SANDRA ELAINE (FNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:ELAINE
Last Name:LEADERS
Suffix:
Gender:F
Credentials:FNP
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 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:
Practice Address - Street 1:415 MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:IA
Practice Address - Zip Code:51551-8137
Practice Address - Country:US
Practice Address - Phone:712-624-9185
Practice Address - Fax:712-624-8827
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA071752363LP2300X
IAA1071752363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1629150669Medicaid
IA0254656Medicaid
IA0638593Medicaid
NE47068731712Medicaid
IA42047Medicare ID - Type UnspecifiedPART B GROUP #