Provider Demographics
NPI:1811974892
Name:WOLLENBERG, SANDRA (NP)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:
Last Name:WOLLENBERG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:753 N MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-3649
Mailing Address - Country:US
Mailing Address - Phone:928-634-7470
Mailing Address - Fax:928-639-3280
Practice Address - Street 1:753 N MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-3649
Practice Address - Country:US
Practice Address - Phone:928-634-7470
Practice Address - Fax:928-639-3280
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR53467363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z22680Medicare PIN