1033242862 NPI number — SANDRA P MERTZ RN, IBCLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033242862 NPI number — SANDRA P MERTZ RN, IBCLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MERTZ
Provider First Name:
SANDRA
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, IBCLC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARLSON
Provider Other First Name:
SANDRA
Provider Other Middle Name:
PALMA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
REGISTERED NURSE
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1033242862
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
533 MAJESTIC PRINCE CIRCLE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAVRE DE GRACE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21078-2795
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-669-4377
Provider Business Mailing Address Fax Number:
443-729-0620

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
533 MAJESTIC PRINCE CIRCLE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAVRE DE GRACE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21078-2795
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-668-4377
Provider Business Practice Location Address Fax Number:
443-729-0620
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WL0100X , with the licence number:  R198259 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1015976760001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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