Provider Demographics
NPI:1760570576
Name:PRYTULA, SANDRA J
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:J
Last Name:PRYTULA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21000 E 12 MILE RD
Mailing Address - Street 2:STE 111
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081
Mailing Address - Country:US
Mailing Address - Phone:586-779-7610
Mailing Address - Fax:586-445-2526
Practice Address - Street 1:21000 E 12 MILE RD
Practice Address - Street 2:SUITE 111
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1116
Practice Address - Country:US
Practice Address - Phone:586-779-7610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000065237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI640E07684OtherBLUE SHIELD
MI0E06192OtherBLUE SHIELD
0E01107OtherBLUE SHIELD
MI540E00292OtherBLUE SHIELD
0E01107OtherBLUE SHIELD