1639765100 NPI number — ANNA IONE SUNDERLAND

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639765100 NPI number — ANNA IONE SUNDERLAND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUNDERLAND
Provider First Name:
ANNA
Provider Middle Name:
IONE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SEVERSON
Provider Other First Name:
ANNA
Provider Other Middle Name:
IONE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1639765100
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
195 TURNBERRY PL APT E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PETERS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63376-4467
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-285-2301
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13612 BIG BEND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALLEY PARK
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63088-1447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-923-8693
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/17/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  2020035172 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)