Provider Demographics
NPI:1689762866
Name:CLOOTEN, SANDRA D (CNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:D
Last Name:CLOOTEN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:D
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:353 FAIRMONT BLVD
Mailing Address - Street 2:ATTEN MEDICAL STAFF SERVICES
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-6000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1445 NORTH AVE
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783
Practice Address - Country:US
Practice Address - Phone:605-644-4170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDSD-CNP CP000350363LF0000X
SDR029388363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily