Provider Demographics
NPI:1336587740
Name:POYNER, SANDRA SLAY
Entity Type:Individual
Prefix:MISS
First Name:SANDRA
Middle Name:SLAY
Last Name:POYNER
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:PO BOX 67
Mailing Address - Street 2:107 H STREET EAST
Mailing Address - City:POPLAR
Mailing Address - State:MT
Mailing Address - Zip Code:59255-0067
Mailing Address - Country:US
Mailing Address - Phone:406-653-1656
Mailing Address - Fax:
Practice Address - Street 1:107 H STREET EAST
Practice Address - Street 2:BOX 67
Practice Address - City:POPLAR
Practice Address - State:MT
Practice Address - Zip Code:59255-0067
Practice Address - Country:US
Practice Address - Phone:406-653-1656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA80859247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT9990118Medicaid