Provider Demographics
NPI:1053347542
Name:TINNEY, SANDRA J (NP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:TINNEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5037
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-5037
Mailing Address - Country:US
Mailing Address - Phone:417-781-9200
Mailing Address - Fax:417-781-9471
Practice Address - Street 1:3202 MCINTOSH CIRCLE
Practice Address - Street 2:SUITE 101
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804
Practice Address - Country:US
Practice Address - Phone:417-781-9200
Practice Address - Fax:417-781-9471
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO096202363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100052950AMedicaid
KS100299510AMedicaid
MO132296OtherANTHEM
500008264OtherRR MEDICARE
MO428931307Medicaid
KS100299510AMedicaid
S52178Medicare UPIN