Provider Demographics
NPI:1013465152
Name:SANDERSON, NICOLE M (NP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:SETSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-927-1756
Mailing Address - Fax:260-479-4639
Practice Address - Street 1:510 SMALTZ WAY
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-0612
Practice Address - Country:US
Practice Address - Phone:260-927-1756
Practice Address - Fax:260-479-4639
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28203112A363LF0000X
IN71006648A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily