Provider Demographics
NPI:1871685792
Name:ANDERSON, SANDY M (APRN-BC)
Entity Type:Individual
Prefix:MRS
First Name:SANDY
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:MRS
Other - First Name:SANDY
Other - Middle Name:MARIE
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, MS, MS, APRN-BC
Mailing Address - Street 1:7271 N MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-2561
Mailing Address - Country:US
Mailing Address - Phone:937-991-0082
Mailing Address - Fax:379-910-0089
Practice Address - Street 1:7271 N MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-2561
Practice Address - Country:US
Practice Address - Phone:937-991-0082
Practice Address - Fax:937-991-0089
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2024-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.254376-C0A1207QA0401X, 363LC1500X
OHRN.254376-COA1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2388901Medicaid
OH000000577058OtherBCBS OHIO
OH9939476OtherAETNA
OH000000577058OtherBCBS OHIO