Provider Demographics
NPI:1578644852
Name:BIRDLEBOUGH, SANDRA L (PHD, ARNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:BIRDLEBOUGH
Suffix:
Gender:F
Credentials:PHD, ARNP
Other - Prefix:
Other - First Name:SANDY
Other - Middle Name:
Other - Last Name:BIRDLEBOUGH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:250 LOOMIS RD
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-8822
Mailing Address - Country:US
Mailing Address - Phone:509-788-0750
Mailing Address - Fax:
Practice Address - Street 1:250 LOOMIS RD
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-8822
Practice Address - Country:US
Practice Address - Phone:509-788-0750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002504103T00000X
WAAP30005617363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9635871Medicaid
WA0195091OtherL&I
WAAB35033Medicare ID - Type UnspecifiedPHD
WA9635871Medicaid