Provider Demographics
NPI:1427523588
Name:PERNECKY, SANDRA D
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:D
Last Name:PERNECKY
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 1:1215 N HURON RIVER DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-2351
Mailing Address - Country:US
Mailing Address - Phone:734-487-3713
Mailing Address - Fax:
Practice Address - Street 1:630 ARCHWOOD DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-2807
Practice Address - Country:US
Practice Address - Phone:734-741-8399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
718222OtherACADEMY OF NUTRITION AND DIETETICS