Provider Demographics
NPI:1538129804
Name:WARDWELL, SANDRA JEAN (WHNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:JEAN
Last Name:WARDWELL
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 STILLWATER AVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3984
Mailing Address - Country:US
Mailing Address - Phone:207-945-6588
Mailing Address - Fax:207-945-2955
Practice Address - Street 1:12 STILLWATER AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3984
Practice Address - Country:US
Practice Address - Phone:207-945-6588
Practice Address - Fax:207-945-2955
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP081892363LW0102X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432937499Medicaid
MEMM9086Medicare PIN
000638201Medicare PIN