Provider Demographics
NPI:1457907248
Name:SANDERSON, TANYA (NP)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:738 S GLOSTER ST STE B
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4932
Mailing Address - Country:US
Mailing Address - Phone:662-630-4005
Mailing Address - Fax:
Practice Address - Street 1:738 S GLOSTER ST STE B
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4932
Practice Address - Country:US
Practice Address - Phone:662-630-4005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-16
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903201363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care