Provider Demographics
NPI:1144472788
Name:SANDSTROM, LISA MARIE (RN)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:SANDSTROM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 ELM CT
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-3409
Mailing Address - Country:US
Mailing Address - Phone:715-499-4949
Mailing Address - Fax:
Practice Address - Street 1:218 ELM CT
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-3409
Practice Address - Country:US
Practice Address - Phone:715-499-4949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI160147-030163W00000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35070500Medicaid