Provider Demographics
NPI:1033880877
Name:RICHARDSON, SANDRA SUE
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:SUE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
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 127
Mailing Address - Street 2:
Mailing Address - City:PENASCO
Mailing Address - State:NM
Mailing Address - Zip Code:87553-0127
Mailing Address - Country:US
Mailing Address - Phone:575-779-6112
Mailing Address - Fax:
Practice Address - Street 1:201-A PUEBLO VIEW ROAD
Practice Address - Street 2:PICURIS PUEBLO
Practice Address - City:PENASCO
Practice Address - State:NM
Practice Address - Zip Code:87553
Practice Address - Country:US
Practice Address - Phone:575-779-6112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker