Provider Demographics
NPI:1962851014
Name:SANDERS, SARA NICOLE (OD)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:NICOLE
Last Name:SANDERS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:NICOLE
Other - Last Name:KENNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:110 COSHOCTON AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-2628
Mailing Address - Country:US
Mailing Address - Phone:740-392-4000
Mailing Address - Fax:
Practice Address - Street 1:110 COSHOCTON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-2628
Practice Address - Country:US
Practice Address - Phone:740-392-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.6470-T3387390200000X
OHOH6470152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program