Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 5272-12 | WI |
N | 111NP0017X | Pediatric Chiropractor | 5272-12 | WI |
NPI | 1114453701 |
---|---|
Provider Name | Victoria Sandstrom |
First Address | Brookfield, WI 53072-2911 |
Second Address | Brookfield, WI 53072-2911 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2017 |
Last Update Date | 03/05/2017 |