Provider Demographics
NPI:1861711707
Name:SANDS, KATHY (RN)
Entity type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:
Last Name:SANDS
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 1:500 NORTH INDIANA AVENUE
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047
Mailing Address - Country:US
Mailing Address - Phone:928-289-4646
Mailing Address - Fax:928-737-6080
Practice Address - Street 1:500 NORTH INDIANA AVENUE
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047
Practice Address - Country:US
Practice Address - Phone:928-289-4646
Practice Address - Fax:928-737-6080
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN070922163W00000X, 163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ020529Medicaid