Provider Demographics
NPI:1386812766
Name:WIEGAND, SANDRA JEAN
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:JEAN
Last Name:WIEGAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:JEAN
Other - Last Name:AKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9035 W MARY ANN DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-6459
Mailing Address - Country:US
Mailing Address - Phone:623-692-1979
Mailing Address - Fax:
Practice Address - Street 1:9035 W MARY ANN DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-6459
Practice Address - Country:US
Practice Address - Phone:623-692-1979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11786171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor