Provider Demographics
NPI:1437154572
Name:MARCY, SANDRA LEE (ANP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:MARCY
Suffix:
Gender:F
Credentials:ANP
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 130
Mailing Address - Street 2:
Mailing Address - City:DEER
Mailing Address - State:AR
Mailing Address - Zip Code:72628-0130
Mailing Address - Country:US
Mailing Address - Phone:870-428-5391
Mailing Address - Fax:870-428-5391
Practice Address - Street 1:1 HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:DEER
Practice Address - State:AR
Practice Address - Zip Code:72628
Practice Address - Country:US
Practice Address - Phone:780-428-5391
Practice Address - Fax:870-428-5391
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP782A363L00000X
ARA01436363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID043634356OtherBRCHC TAX ID
ID806590100Medicaid
ID8H104OtherBLUE CROSS OF ID GROUP
ID000010142695OtherREGENCE OF ID GROUP
ID000010160675OtherREGENCE OF ID
IDNPYH4OtherBLUE CROSS OF ID
ID000010142695OtherREGENCE OF ID GROUP
ID8H104OtherBLUE CROSS OF ID GROUP
IDNPYH4OtherBLUE CROSS OF ID
ID131832Medicare ID - Type UnspecifiedMEDICARE PART A