Provider Demographics
NPI:1235251208
Name:MCLOUGHLIN, SANDRA ANN (APRN)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:ANN
Last Name:MCLOUGHLIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-725-4500
Mailing Address - Fax:
Practice Address - Street 1:1223 GATEWAY DR STE 2D
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-725-4500
Practice Address - Fax:321-956-2540
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN2567682363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016245100Medicaid
P01165539OtherFL RR MEDICARE
FLU3089WOtherMEDICARE