Healthcare Provider Details

I. General information

NPI: 1063568509
Provider Name (Legal Business Name): SANDY PANKRATZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2178 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4535
US

IV. Provider business mailing address

129 W JONES ST APT C
SANTA MARIA CA
93458-5675
US

V. Phone/Fax

Practice location:
  • Phone: 805-781-4711
  • Fax:
Mailing address:
  • Phone: 805-352-9294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT27406
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: