Healthcare Provider Details

I. General information

NPI: 1043210990
Provider Name (Legal Business Name): SANDRA WIGEN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 08/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6075 E BROAD ST
COLUMBUS OH
43213-1549
US

IV. Provider business mailing address

1125 YARD ST STE 200
GRANDVIEW HEIGHTS OH
43212-3930
US

V. Phone/Fax

Practice location:
  • Phone: 614-434-2400
  • Fax: 614-434-2499
Mailing address:
  • Phone: 614-434-2400
  • Fax: 614-434-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberNP01913
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberRN200521
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: