MEDICARE: GENEVA AUSTAR SANDERS APRN, FNP, PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	209.020599	IL
2	363L00000X	Nurse Practitioner	209.020599	IL
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	209.020599	IL

General Provider Information

NPI Number	:	1689212409
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENEVA AUSTAR SANDERS APRN, FNP, PMHNP

Provider Business Mailing Address
First Line	:	3008 HAPPY LANDING DR
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62711-6259
Country	:	US
Telephone Number	:	630-328-0942
Fax Number	:

Provider Business Practice Location Address
First Line	:	3008 HAPPY LANDING DR
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62711-6259
Country	:	US
Telephone Number	:	630-328-0942
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2019
Last Update Date	:	09/20/2023

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