Provider Demographics
NPI:1417015462
Name:PUTNAM, SANDRA T (APMHNP)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:T
Last Name:PUTNAM
Suffix:
Gender:F
Credentials:APMHNP
Other - Prefix:MS
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:TILLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APMHNP
Mailing Address - Street 1:48 GILMAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3004
Mailing Address - Country:US
Mailing Address - Phone:207-662-2295
Mailing Address - Fax:207-662-6116
Practice Address - Street 1:48 GILMAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3004
Practice Address - Country:US
Practice Address - Phone:207-662-2295
Practice Address - Fax:207-662-6116
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER025074363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MENP3173Medicare PIN
MENP317302Medicare PIN