Provider Demographics
NPI:1083941926
Name:KENNEDY SAAM, SANDRA KAY
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:KAY
Last Name:KENNEDY SAAM
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:PO BOX 1973
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:WY
Mailing Address - Zip Code:83014-1973
Mailing Address - Country:US
Mailing Address - Phone:307-200-1926
Mailing Address - Fax:
Practice Address - Street 1:5755 SOUTH HWY 89
Practice Address - Street 2:#15
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-200-1926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-13
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1288343000171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor