Provider Demographics
NPI:1417598061
Name:SANDSTROM, JUSTINE R
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:R
Last Name:SANDSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 CANDLEWOOD DR APT A
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-6654
Mailing Address - Country:US
Mailing Address - Phone:620-342-4327
Mailing Address - Fax:
Practice Address - Street 1:2715 CANDLEWOOD DR APT A
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801-6654
Practice Address - Country:US
Practice Address - Phone:620-342-4327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1470237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter