Provider Demographics
NPI:1356937726
Name:SANDBECK, DEBRA JANE
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:JANE
Last Name:SANDBECK
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 1:2717 11TH AVE N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-3107
Mailing Address - Country:US
Mailing Address - Phone:701-367-5837
Mailing Address - Fax:
Practice Address - Street 1:2717 11TH AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3107
Practice Address - Country:US
Practice Address - Phone:701-367-5837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1475694253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1475694Medicaid