Provider Demographics
NPI:1386762862
Name:SANDERS, STACYANN ELLEN (OTA)
Entity type:Individual
Prefix:
First Name:STACYANN
Middle Name:ELLEN
Last Name:SANDERS
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 HARBISON DRIVE APT. 202
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95768-9232
Mailing Address - Country:US
Mailing Address - Phone:707-880-1291
Mailing Address - Fax:
Practice Address - Street 1:350 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-7028
Practice Address - Country:US
Practice Address - Phone:386-677-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA10091224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant