Basic Information
| Provider Information | |||||||||
| NPI: | 1679509558 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MSN, ARNP, BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 NW 10TH AVE | ||||||||
| Address2: | DOMINION TOWER, #813A | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052434598 | ||||||||
| FaxNumber: | 3052434037 | ||||||||
| Practice Location | |||||||||
| Address1: | 1611 NW 12TH AVE | ||||||||
| Address2: | BOX 016960 M851 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052434664 | ||||||||
| FaxNumber: | 3052438470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 07/10/2007 | ||||||||
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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 | 363L00000X | ARNP1231282 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | ARNP1231282 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 3049779-00 | 05 | FL | MEDICAID |