Healthcare Provider Details

I. General information

NPI: 1891786414
Provider Name (Legal Business Name): SANDRA K HEADRICK A.P.R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 BLUES LAKE PKWY
ROLLA MO
65401-8022
US

IV. Provider business mailing address

1415 W SCENIC RIVERS BLVD
SALEM MO
65560-2840
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-5719
  • Fax: 573-364-6493
Mailing address:
  • Phone: 573-729-5533
  • Fax: 573-202-2466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number128892
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: