Provider Demographics
NPI:1326154154
Name:SANDIE, COLLEEN L (CRNA, MS)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:L
Last Name:SANDIE
Suffix:
Gender:F
Credentials:CRNA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 G AVE
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-1215
Mailing Address - Country:US
Mailing Address - Phone:901-687-7204
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-4602
Practice Address - Country:US
Practice Address - Phone:619-532-8943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2322367500000X
VA00024166167367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010243149Medicaid
007463B25Medicare PIN