Individual
MRS. SANDRA DEAN MUMFORD
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
2600 GREENBUSH ST, LAFAYETTE, IN 47904-2477
(765) 448-8000
(765) 838-5150
Mailing address
2401 W BELVEDERE AVE, BALTIMORE, MD 21215-5216
(410) 601-5209
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
28240085A
IN
367500000X
Certified Registered Nurse Anesthetist
Primary
86009
IN
367500000X
Certified Registered Nurse Anesthetist
N-20588
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
300008420
—
IN
01
—
PENDING
ANTHEM PROVIDER NUMBER
IN
Enumeration date
01/28/2011
Last updated
03/17/2018
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