Healthcare Provider Details

I. General information

NPI: 1790649168
Provider Name (Legal Business Name): SISTERHOOD SANCTUARY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1842 SUGARLAND DR STE 101
SHERIDAN WY
82801-5719
US

IV. Provider business mailing address

48 LANDON LN
SHERIDAN WY
82801-9014
US

V. Phone/Fax

Practice location:
  • Phone: 307-763-8701
  • Fax: 307-224-2239
Mailing address:
  • Phone: 307-752-5078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ASHTON MCCOMB
Title or Position: MA
Credential:
Phone: 307-752-5078