Provider Demographics
NPI:1316712060
Name:SANDERS, STAVONNE
Entity type:Individual
Prefix:
First Name:STAVONNE
Middle Name:
Last Name:SANDERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6342 W VALENCIA DR
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-2775
Mailing Address - Country:US
Mailing Address - Phone:623-221-6092
Mailing Address - Fax:
Practice Address - Street 1:6342 W VALENCIA DR
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-2775
Practice Address - Country:US
Practice Address - Phone:623-221-6092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251E00000X, 253Z00000X, 343900000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No385H00000XRespite Care FacilityRespite Care