Provider Demographics
NPI:1730997396
Name:SANDALL, STACIE
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:SANDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 NORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:MC COOK
Mailing Address - State:NE
Mailing Address - Zip Code:69001-3144
Mailing Address - Country:US
Mailing Address - Phone:308-340-1165
Mailing Address - Fax:
Practice Address - Street 1:110 E E ST
Practice Address - Street 2:
Practice Address - City:MC COOK
Practice Address - State:NE
Practice Address - Zip Code:69001-2049
Practice Address - Country:US
Practice Address - Phone:308-340-1165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-27
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE54739511373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist