Provider Demographics
NPI:1659641066
Name:MONGEON, SANDRA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:MONGEON
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 1:41 OCONNOR RD
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-1327
Mailing Address - Country:US
Mailing Address - Phone:585-325-7828
Mailing Address - Fax:585-324-7620
Practice Address - Street 1:41 OCONNOR RD
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-1327
Practice Address - Country:US
Practice Address - Phone:585-325-7828
Practice Address - Fax:585-324-7620
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22464964163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool