Healthcare Provider Details

I. General information

NPI: 1023228384
Provider Name (Legal Business Name): SANDRA D HARRISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N 92ND ST
MILWAUKEE WI
53226-3533
US

IV. Provider business mailing address

3906 N SHERMAN BLVD APT 4
MILWAUKEE WI
53216-2460
US

V. Phone/Fax

Practice location:
  • Phone: 414-479-9400
  • Fax: 414-259-1663
Mailing address:
  • Phone: 414-479-9400
  • Fax: 414-259-1663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberH625-7846-1720-08
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: