Basic Information
| Provider Information | |||||||||
| NPI: | 1558329292 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDERS | ||||||||
| FirstName: | SHIRLEY | ||||||||
| MiddleName: | JOANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NURSE PRACTITIONER | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRUENJES | ||||||||
| OtherFirstName: | SHIRLEY | ||||||||
| OtherMiddleName: | JOANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 806 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472016264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127483412 | ||||||||
| FaxNumber: | 8123776024 | ||||||||
| Practice Location | |||||||||
| Address1: | 3203 MIDDLE ROAD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472034427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123732700 | ||||||||
| FaxNumber: | 8123732710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 08/03/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71000212 | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 000000990928 | 01 | IN | ANTHEM PIN | OTHER | 054962P | 01 | IN | SIHO | OTHER | 201085480 | 05 | IN | MEDICAID | 500011512 | 01 | IN | MEDICARE RAILROAD | OTHER | 71000212 | 01 | IN | IN NP LINCENSE | OTHER | 1407861164 | 01 | GROUP NPI | OTHER |