Provider Demographics
NPI:1720091085
Name:DEITCH, SANDRA H (CNM, NP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:H
Last Name:DEITCH
Suffix:
Gender:F
Credentials:CNM, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 PINE ST
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-6236
Mailing Address - Country:US
Mailing Address - Phone:845-638-3948
Mailing Address - Fax:845-639-4178
Practice Address - Street 1:716 BROAD ST
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-1645
Practice Address - Country:US
Practice Address - Phone:973-928-2912
Practice Address - Fax:973-928-2915
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR05729800163W00000X
NJ25ME00008000367A00000X
NYF360015364SW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
No364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR45382Medicare UPIN
NYM2M581Medicare ID - Type Unspecified