1093099269 NPI number — SANDRA A. BOERNER APNP

Table of content: SANDRA A. BOERNER APNP (NPI 1093099269)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093099269 NPI number — SANDRA A. BOERNER APNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOERNER
Provider First Name:
SANDRA
Provider Middle Name:
A.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093099269
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1311 N PORT WASHINGTON RD, RM 121
Provider Second Line Business Mailing Address:
ATTN: PALLIATIVE CARE PROGRAM
Provider Business Mailing Address City Name:
MEQUON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53097
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-243-8453
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N143W6515 PIONEER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CEDARBURG
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53012-2705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-377-6933
Provider Business Practice Location Address Fax Number:
262-376-2495
Provider Enumeration Date:
10/05/2011

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: 363LF0000X , with the licence number:  4634-33 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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