Provider Demographics
NPI:1083669154
Name:SANDERBECK-BARONE, THERESA (CNP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:SANDERBECK-BARONE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 TRAILWOOD DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-5008
Mailing Address - Country:US
Mailing Address - Phone:330-758-7575
Mailing Address - Fax:330-758-1833
Practice Address - Street 1:925 TRAILWOOD DR
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-5008
Practice Address - Country:US
Practice Address - Phone:330-758-7575
Practice Address - Fax:330-758-1833
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP05924363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2282220Medicaid
OHSANP09612Medicare ID - Type Unspecified