Basic Information
| Provider Information | |||||||||
| NPI: | 1265697320 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIAN | ||||||||
| FirstName: | SANDY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHELLEY | ||||||||
| OtherFirstName: | SANDY | ||||||||
| OtherMiddleName: | L. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 406153 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303841876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614788770 | ||||||||
| FaxNumber: | 5616888877 | ||||||||
| Practice Location | |||||||||
| Address1: | 4301 CANAL AVE SW | ||||||||
| Address2: | |||||||||
| City: | GRANDVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494182667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162577880 | ||||||||
| FaxNumber: | 6162570580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2008 | ||||||||
| LastUpdateDate: | 09/09/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | MI | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 237700000X | 3501004909 | MI | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.