Provider Demographics
NPI:1013249929
Name:SANDERSON, PENNY MARIE (APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:MARIE
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 NW SPRUCE
Mailing Address - Street 2:
Mailing Address - City:RAWLINS
Mailing Address - State:WY
Mailing Address - Zip Code:82301-0460
Mailing Address - Country:US
Mailing Address - Phone:307-324-8494
Mailing Address - Fax:307-324-8496
Practice Address - Street 1:1517 BROADWAY
Practice Address - Street 2:SUITE 124
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-3184
Practice Address - Country:US
Practice Address - Phone:308-635-2800
Practice Address - Fax:308-635-2801
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY30342.1158363LF0000X
NE111108363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47051963312Medicaid
NE10025914400Medicaid