Provider Demographics
NPI:1033242862
Name:MERTZ, SANDRA P (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:P
Last Name:MERTZ
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:PALMA
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:533 MAJESTIC PRINCE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-2795
Mailing Address - Country:US
Mailing Address - Phone:443-669-4377
Mailing Address - Fax:443-729-0620
Practice Address - Street 1:533 MAJESTIC PRINCE CIRCLE
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-2795
Practice Address - Country:US
Practice Address - Phone:443-668-4377
Practice Address - Fax:443-729-0620
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR198259163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1015976760001Medicaid