Provider Demographics
NPI:1629159447
Name:HERRING, SANDRA LYN (LAT, ATC)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:LYN
Last Name:HERRING
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 VICTORY HL
Mailing Address - Street 2:
Mailing Address - City:COATESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46121-8962
Mailing Address - Country:US
Mailing Address - Phone:765-386-6211
Mailing Address - Fax:
Practice Address - Street 1:5949 W RAYMOND ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-4348
Practice Address - Country:US
Practice Address - Phone:317-390-5590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000297A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN36000297AOtherATHLETIC TRAINER LICENSE