Healthcare Provider Details

I. General information

NPI: 1710967625
Provider Name (Legal Business Name): SANDRA J RACKLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18432 KENRICK AVE
LAKEVILLE MN
55044-9288
US

IV. Provider business mailing address

18432 KENRICK AVE
LAKEVILLE MN
55044-9288
US

V. Phone/Fax

Practice location:
  • Phone: 952-992-6750
  • Fax:
Mailing address:
  • Phone: 952-992-6750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number48197
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number48197
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: