Provider Demographics
NPI:1700826427
Name:MINNICK, SANDRA LYNN (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:LYNN
Last Name:MINNICK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:715 WOLLUPS HILL RD
Mailing Address - Street 2:
Mailing Address - City:STEVENS
Mailing Address - State:PA
Mailing Address - Zip Code:17578-9346
Mailing Address - Country:US
Mailing Address - Phone:717-336-1039
Mailing Address - Fax:
Practice Address - Street 1:136 A&B LAKE STREET
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-2415
Practice Address - Country:US
Practice Address - Phone:717-721-7718
Practice Address - Fax:717-721-7726
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP003366B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMI00523Medicare PIN
PAS49366Medicare UPIN