Provider Demographics
NPI:1356872493
Name:SANNER, CASEY
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:SANNER
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 1:128 LAKESIDE AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4936
Mailing Address - Country:US
Mailing Address - Phone:802-860-1928
Mailing Address - Fax:802-860-0192
Practice Address - Street 1:128 LAKESIDE AVE STE 115
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4936
Practice Address - Country:US
Practice Address - Phone:802-860-1928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0014955208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics