Provider Demographics
NPI:1801247556
Name:AVY, SANDRA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:AVY
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 1:520 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1507
Mailing Address - Country:US
Mailing Address - Phone:208-263-1441
Mailing Address - Fax:
Practice Address - Street 1:520 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1507
Practice Address - Country:US
Practice Address - Phone:208-263-1441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2024-10-29
Deactivation Date:2023-12-05
Deactivation Code:
Reactivation Date:2023-12-20
Provider Licenses
StateLicense IDTaxonomies
IDTEMP78136363LF0000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst