Provider Demographics
NPI:1811966252
Name:BOOMER, SANDRA L (FNP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:BOOMER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1848
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1848
Mailing Address - Country:US
Mailing Address - Phone:231-727-4444
Mailing Address - Fax:231-727-4451
Practice Address - Street 1:3535 PARK ST
Practice Address - Street 2:SUITE 110
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-3736
Practice Address - Country:US
Practice Address - Phone:231-733-3155
Practice Address - Fax:231-737-1535
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704110400363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ38436Medicare UPIN