Provider Demographics
NPI:1407880131
Name:NETTINA, SANDRA M (CRNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:M
Last Name:NETTINA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2760 WYNFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WEST FRIENDSHIP
Mailing Address - State:MD
Mailing Address - Zip Code:21794-9519
Mailing Address - Country:US
Mailing Address - Phone:410-336-3385
Mailing Address - Fax:410-489-5169
Practice Address - Street 1:2760 WYNFIELD RD
Practice Address - Street 2:
Practice Address - City:WEST FRIENDSHIP
Practice Address - State:MD
Practice Address - Zip Code:21794-9519
Practice Address - Country:US
Practice Address - Phone:410-336-3385
Practice Address - Fax:410-489-5169
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR109061363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD006NK053Medicare ID - Type Unspecified
P92432Medicare UPIN