Provider Demographics
NPI:1720662455
Name:SANCTUM INTEGRATED HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:SANCTUM INTEGRATED HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:NINA
Authorized Official - Middle Name:C
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-472-6288
Mailing Address - Street 1:224 E MAIN ST STE 119
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-5790
Mailing Address - Country:US
Mailing Address - Phone:866-472-6288
Mailing Address - Fax:856-389-5716
Practice Address - Street 1:224 E MAIN ST STE 119
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-5790
Practice Address - Country:US
Practice Address - Phone:866-472-6288
Practice Address - Fax:856-389-5716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-10
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJL04095926355682OtherDL
MD907607700Medicaid