Provider Demographics
NPI:1881298156
Name:LANDIVAR, SANDRA JACQUELINE
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:JACQUELINE
Last Name:LANDIVAR
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 1:170 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-8904
Mailing Address - Country:US
Mailing Address - Phone:203-276-2472
Mailing Address - Fax:203-276-4594
Practice Address - Street 1:170 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-8904
Practice Address - Country:US
Practice Address - Phone:203-276-2472
Practice Address - Fax:203-276-4594
Is Sole Proprietor?:No
Enumeration Date:2020-11-26
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10436363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health