Healthcare Provider Details

I. General information

NPI: 1396295044
Provider Name (Legal Business Name): SANDRA LANDRY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SANDRA HYAMS

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1617 HEMPHILL ST
FORT WORTH TX
76104-4709
US

IV. Provider business mailing address

200 1ST ST SW
ROCHESTER MN
55905-0001
US

V. Phone/Fax

Practice location:
  • Phone: 817-702-3100
  • Fax: 817-702-4847
Mailing address:
  • Phone: 507-284-2511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number839596
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number239164-9
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4796
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP 4796
License Number StateMN
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1006644
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: