MEDICARE: MS. SANDRIA R NIXON DR. FNP

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	363L00000X	Nurse Practitioner	4704141786	MI
2	363LF0000X	Family Nurse Practitioner	71001771A	IN
3	363L00000X	Nurse Practitioner	71001771A	IN

General Provider Information

NPI Number	:	1104817733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SANDRIA R NIXON DR. FNP

Provider Business Mailing Address
First Line	:	500 KIRTS BLVD STE 100
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48084-4135
Country	:	US
Telephone Number	:	484-346-1692
Fax Number	:	855-618-6655

Provider Business Practice Location Address
First Line	:	211 N EDDY ST.
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46617-3096
Country	:	US
Telephone Number	:	574-237-9331
Fax Number	:	574-237-9252

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

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	02/08/2021

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