Healthcare Provider Details

I. General information

NPI: 1548925423
Provider Name (Legal Business Name): JACQUIN MARIE SANDS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2021
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3680 NE AKIN DR STE 114
LEES SUMMIT MO
64064-7853
US

IV. Provider business mailing address

3680 NE AKIN DR STE 114
LEES SUMMIT MO
64064-7853
US

V. Phone/Fax

Practice location:
  • Phone: 816-974-6576
  • Fax:
Mailing address:
  • Phone: 816-974-6576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2015011980
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: