Provider Demographics
NPI:1831315415
Name:DITTMER, SANDRA LOUISE
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:LOUISE
Last Name:DITTMER
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 1:67464 250TH ST
Mailing Address - Street 2:
Mailing Address - City:COLO
Mailing Address - State:IA
Mailing Address - Zip Code:50056-8614
Mailing Address - Country:US
Mailing Address - Phone:641-377-2922
Mailing Address - Fax:
Practice Address - Street 1:67464 250TH ST
Practice Address - Street 2:
Practice Address - City:COLO
Practice Address - State:IA
Practice Address - Zip Code:50056-8614
Practice Address - Country:US
Practice Address - Phone:641-377-2922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA4285081261QM3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0256727Medicaid