Provider Demographics
NPI:1104015742
Name:NIENABER, SANDRA S
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:S
Last Name:NIENABER
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 1:1601 PARKVIEW AVE
Mailing Address - Street 2:S200
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1822
Mailing Address - Country:US
Mailing Address - Phone:815-395-5851
Mailing Address - Fax:815-395-5644
Practice Address - Street 1:420 E STATE ST
Practice Address - Street 2:WINNEBAGO COUNTY JAIL
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-1015
Practice Address - Country:US
Practice Address - Phone:815-319-6634
Practice Address - Fax:815-395-5644
Is Sole Proprietor?:No
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005207363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK21095Medicare PIN