Provider Demographics
NPI:1164622254
Name:WIELAND, SANDRA KELLEY (CRNP-PMH)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:KELLEY
Last Name:WIELAND
Suffix:
Gender:F
Credentials:CRNP-PMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 CHESAPEAKE DR STE 1
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-9405
Mailing Address - Country:US
Mailing Address - Phone:410-221-2266
Mailing Address - Fax:410-221-2878
Practice Address - Street 1:813 CHESAPEAKE DR STE 1
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-9405
Practice Address - Country:US
Practice Address - Phone:410-221-2266
Practice Address - Fax:410-221-2878
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRO38366363LF0000X
MDR038366363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD479302100Medicaid
MD415081300Medicaid