Provider Demographics
NPI:1104817733
Name:NIXON, SANDRIA R (DR FNP)
Entity type:Individual
Prefix:MS
First Name:SANDRIA
Middle Name:R
Last Name:NIXON
Suffix:
Gender:F
Credentials:DR FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 KIRTS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4135
Mailing Address - Country:US
Mailing Address - Phone:484-346-1692
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:211 N EDDY ST.
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3096
Practice Address - Country:US
Practice Address - Phone:574-237-9331
Practice Address - Fax:574-237-9252
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704141786363L00000X
IN71001771A363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P30260Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
MIP30260002Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
MIQ24426Medicare UPIN