Provider Demographics
NPI:1265198246
Name:SANDER, MIRANDA NICOLE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:NICOLE
Last Name:SANDER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:NICOLE
Other - Last Name:ROHLFING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1176 TOWN AND COUNTRY COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:TOWN AND COUNTRY
Mailing Address - State:MO
Mailing Address - Zip Code:63017-8200
Mailing Address - Country:US
Mailing Address - Phone:217-663-5669
Mailing Address - Fax:
Practice Address - Street 1:1176 TOWN AND COUNTRY COMMONS DR
Practice Address - Street 2:
Practice Address - City:TOWN AND COUNTRY
Practice Address - State:MO
Practice Address - Zip Code:63017-8200
Practice Address - Country:US
Practice Address - Phone:217-663-5669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-13
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017024672163W00000X
IL041504517163W00000X
MO2021046352363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse