Provider Demographics
NPI:1093231177
Name:ROLLER, SANDRA MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:MARIE
Last Name:ROLLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 POWDER MILL RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-2655
Mailing Address - Country:US
Mailing Address - Phone:609-634-6086
Mailing Address - Fax:
Practice Address - Street 1:90 POWDER MILL RD
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-2655
Practice Address - Country:US
Practice Address - Phone:609-634-6086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP06092200164W00000X
NY309262164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse