Healthcare Provider Details

I. General information

NPI: 1265198246
Provider Name (Legal Business Name): MIRANDA NICOLE SANDER PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MIRANDA NICOLE ROHLFING

II. Dates (important events)

Enumeration Date: 11/13/2021
Last Update Date: 04/04/2022
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1176 TOWN AND COUNTRY COMMONS DR
TOWN AND COUNTRY MO
63017-8200
US

IV. Provider business mailing address

1176 TOWN AND COUNTRY COMMONS DR
TOWN AND COUNTRY MO
63017-8200
US

V. Phone/Fax

Practice location:
  • Phone: 217-663-5669
  • Fax:
Mailing address:
  • Phone: 217-663-5669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2021046352
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2017024672
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041504517
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: