Provider Demographics
NPI:1023084183
Name:STENNETT, SANDRA FAYE (PAC)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:FAYE
Last Name:STENNETT
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1532 BRIDGE RD APT A
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-1900
Mailing Address - Country:US
Mailing Address - Phone:304-541-7763
Mailing Address - Fax:
Practice Address - Street 1:1532 BRIDGE RD APT A
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-1900
Practice Address - Country:US
Practice Address - Phone:304-541-7763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA895363A00000X
WV01204363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95005708Medicaid
WV001906149OtherMS BCBS
WV3810006840Medicaid
KY0783607Medicare PIN
KY95005708Medicaid
WVPA82851Medicare PIN
WV001906149OtherMS BCBS
WVPA23773Medicare PIN
WV3810006840Medicaid