Basic Information
| Provider Information | |||||||||
| NPI: | 1326151085 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDERS | ||||||||
| FirstName: | LAVONNA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9900 E 570 RD | ||||||||
| Address2: | |||||||||
| City: | CATOOSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740156294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183440807 | ||||||||
| FaxNumber: | 9182660170 | ||||||||
| Practice Location | |||||||||
| Address1: | 1202 N MUSKOGEE PL | ||||||||
| Address2: | |||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740173058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183412556 | ||||||||
| FaxNumber: | 9183422304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 04/05/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R49134 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 100783920A | 05 | OK | MEDICAID | 1285810051 | 01 | OK | MEDICARE GROUP PIN | OTHER |