Provider Demographics
NPI:1245995935
Name:SANDERS, MADELYNE ELYSE
Entity type:Individual
Prefix:
First Name:MADELYNE
Middle Name:ELYSE
Last Name:SANDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:MO
Mailing Address - Zip Code:65254-1314
Mailing Address - Country:US
Mailing Address - Phone:660-728-9949
Mailing Address - Fax:
Practice Address - Street 1:600 W MORRISON ST
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MO
Practice Address - Zip Code:65248-1471
Practice Address - Country:US
Practice Address - Phone:660-248-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021045364363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health