Provider Demographics
NPI:1578503850
Name:LERCH, SANDRA THERESA (C FNP CNM)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:THERESA
Last Name:LERCH
Suffix:
Gender:F
Credentials:C FNP CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9487
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-9487
Mailing Address - Country:US
Mailing Address - Phone:307-733-4585
Mailing Address - Fax:307-733-4787
Practice Address - Street 1:320 E BROADWAY
Practice Address - Street 2:STE 1C
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-733-4585
Practice Address - Fax:307-733-4787
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYWY180540164367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY11694100Medicaid