Healthcare Provider Details

I. General information

NPI: 1619165727
Provider Name (Legal Business Name): SANDRA ANN MEAD APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 HWY 138
WALL NJ
07719-3700
US

IV. Provider business mailing address

173 CLEVELAND CT
BRICK NJ
08724-1707
US

V. Phone/Fax

Practice location:
  • Phone: 732-681-8141
  • Fax:
Mailing address:
  • Phone: 732-864-6748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NJ00026200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: