Provider Demographics
NPI:1558399113
Name:DODGE, SANDRA (APRN,BC)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:
Last Name:DODGE
Suffix:
Gender:F
Credentials:APRN,BC
Other - Prefix:MS
Other - First Name:SANDRA
Other - Middle Name:BEGAY
Other - Last Name:DODGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNP
Mailing Address - Street 1:PO BOX PH
Mailing Address - Street 2:CCHCF
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503
Mailing Address - Country:US
Mailing Address - Phone:928-674-7420
Mailing Address - Fax:928-674-7461
Practice Address - Street 1:HIGHWAY 191 AND PH DRIVE
Practice Address - Street 2:
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503
Practice Address - Country:US
Practice Address - Phone:928-674-7420
Practice Address - Fax:928-674-7461
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR18238363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3102957Medicaid
NMQ02281Medicare UPIN
NM8HBU37Medicare ID - Type Unspecified