Healthcare Provider Details

I. General information

NPI: 1124396072
Provider Name (Legal Business Name): SANDRA R GATES-MANNA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2011
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 BROADWAY
GARY IN
46407-2238
US

IV. Provider business mailing address

1701 BROADWAY
GARY IN
46407-2238
US

V. Phone/Fax

Practice location:
  • Phone: 219-949-7540
  • Fax: 219-949-7545
Mailing address:
  • Phone: 219-949-7540
  • Fax: 219-949-7545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28125285A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71003896A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: