Basic Information
| Provider Information | |||||||||
| NPI: | 1861711707 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDS | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 500 NORTH INDIANA AVENUE | ||||||||
| Address2: | |||||||||
| City: | WINSLOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282894646 | ||||||||
| FaxNumber: | 9287376080 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 NORTH INDIANA AVENUE | ||||||||
| Address2: | |||||||||
| City: | WINSLOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282894646 | ||||||||
| FaxNumber: | 9287376080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2010 | ||||||||
| LastUpdateDate: | 03/18/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN070922 | AZ | N | Nursing Service Providers | Registered Nurse | 163WP2201X | RN070922 | AZ | Y | Nursing Service Providers | Registered Nurse | Ambulatory Care |
ID Information
| ID | Type | State | Issuer | Description | 020529 | 05 | AZ | MEDICAID |