Healthcare Provider Details

I. General information

NPI: 1558718940
Provider Name (Legal Business Name): SANDRA MARTINI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7306 ROUND LAKE RD NW
RAPID CITY MI
49676-9494
US

IV. Provider business mailing address

7306 ROUND LAKE RD NW
RAPID CITY MI
49676-9494
US

V. Phone/Fax

Practice location:
  • Phone: 231-676-7193
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704243487
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: