Healthcare Provider Details

I. General information

NPI: 1588977888
Provider Name (Legal Business Name): MARY K SAND RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 07/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 6TH ST
NEVADA IA
50201-1825
US

IV. Provider business mailing address

245 TODD CIR
AMES IA
50014-7773
US

V. Phone/Fax

Practice location:
  • Phone: 515-231-3159
  • Fax:
Mailing address:
  • Phone: 515-290-5827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number00844
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: