Healthcare Provider Details

I. General information

NPI: 1659643054
Provider Name (Legal Business Name): DALE MICHAEL SANDERSON N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2012
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 CONSTANTIN BLVD
BATON ROUGE LA
70809-3489
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 225-374-4325
  • Fax:
Mailing address:
  • Phone: 225-765-5727
  • Fax: 225-765-4278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberTAP002754
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberAP06807
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: