Healthcare Provider Details

I. General information

NPI: 1063492718
Provider Name (Legal Business Name): SANDY MEADE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 12/08/2019
Certification Date: 12/08/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1639 N ALPINE RD STE 260
ROCKFORD IL
61107-1481
US

IV. Provider business mailing address

4700 DRESSER DR STE 100
JANESVILLE WI
53546-9160
US

V. Phone/Fax

Practice location:
  • Phone: 815-395-1500
  • Fax:
Mailing address:
  • Phone: 815-395-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2645-033
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: