Provider Demographics
NPI:1073570891
Name:CHAMPLIN, SANDRA (PT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:CHAMPLIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 BLUEGRASS CIR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-7355
Mailing Address - Country:US
Mailing Address - Phone:307-773-8533
Mailing Address - Fax:307-635-7578
Practice Address - Street 1:1951 BLUEGRASS CIR
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-7355
Practice Address - Country:US
Practice Address - Phone:307-773-8533
Practice Address - Fax:307-635-7578
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY250225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY650019472OtherRAILROAD MEDICARE
WY115862700Medicaid
WY310613OtherBC/BS
WYW310337Medicare ID - Type Unspecified
WY310613OtherBC/BS