Provider Demographics
NPI:1568583847
Name:SANNA, MARY SANDRA (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SANDRA
Last Name:SANNA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:SANDY
Other - Middle Name:
Other - Last Name:SANNA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:550 SW 3RD ST APT 5
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-4902
Mailing Address - Country:US
Mailing Address - Phone:541-265-0426
Mailing Address - Fax:
Practice Address - Street 1:38 SW NYE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-3821
Practice Address - Country:US
Practice Address - Phone:541-265-0426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR082009845RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO49120361Medicaid