Healthcare Provider Details

I. General information

NPI: 1659641066
Provider Name (Legal Business Name): SANDRA MONGEON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2012
Last Update Date: 01/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 OCONNOR RD
FAIRPORT NY
14450-1327
US

IV. Provider business mailing address

41 OCONNOR RD
FAIRPORT NY
14450-1327
US

V. Phone/Fax

Practice location:
  • Phone: 585-325-7828
  • Fax: 585-324-7620
Mailing address:
  • Phone: 585-325-7828
  • Fax: 585-324-7620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number22464964
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: