Provider Demographics
NPI:1174941553
Name:TRUMBACH, SANDRA SMITH (NNP BC)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:SMITH
Last Name:TRUMBACH
Suffix:
Gender:F
Credentials:NNP BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 DRINKWATER RD
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39520-1658
Mailing Address - Country:US
Mailing Address - Phone:228-467-8600
Mailing Address - Fax:
Practice Address - Street 1:149 DRINKWATER RD
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-1658
Practice Address - Country:US
Practice Address - Phone:228-467-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP03208363LN0005X
MSR892886363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care