Healthcare Provider Details

I. General information

NPI: 1043917644
Provider Name (Legal Business Name): LORA D SANDERS NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2023
Last Update Date: 10/22/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 S MCINTIRE DR STE 150A
BLOOMINGTON IN
47403-4221
US

IV. Provider business mailing address

2920 S MCINTIRE DR STE 150A
BLOOMINGTON IN
47403-4221
US

V. Phone/Fax

Practice location:
  • Phone: 765-349-6793
  • Fax: 765-349-6949
Mailing address:
  • Phone: 765-349-6793
  • Fax: 765-349-6949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number71013418A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71013418A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: