Provider Demographics
NPI:1487840450
Name:HABERMAAS-HEROLD, SANDRA M (CRNA)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:M
Last Name:HABERMAAS-HEROLD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8054
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:636-344-1065
Mailing Address - Fax:636-344-1064
Practice Address - Street 1:2 PROGRESS POINT CT
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-2208
Practice Address - Country:US
Practice Address - Phone:636-344-1065
Practice Address - Fax:636-344-1064
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO063644367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
600420005Medicare PIN