Provider Demographics
NPI:1720387160
Name:STILLWAGGON, SANDRA LEE (LPN)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:STILLWAGGON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 MOTT AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08016-2424
Mailing Address - Country:US
Mailing Address - Phone:609-387-5387
Mailing Address - Fax:
Practice Address - Street 1:2250 HICKORY RD.
Practice Address - Street 2:SUITE 240
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462
Practice Address - Country:US
Practice Address - Phone:609-589-7703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP05606200164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse