Basic Information
| Provider Information | |||||||||
| NPI: | 1396830352 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANDERS | ||||||||
| FirstName: | TEENA | ||||||||
| MiddleName: | YVONNE | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 LAKEVIEW DR | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329513231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3219562345 | ||||||||
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| Practice Location | |||||||||
| Address1: | 775 MALABAR RD | ||||||||
| Address2: | |||||||||
| City: | MALABAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329503155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217228435 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 05/14/2013 | ||||||||
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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 | 363LP0200X | 3178122 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3043592 00 | 05 | FL | MEDICAID |