Provider Demographics
NPI:1871899781
Name:YOUNGBEAR, SALLY J (RN)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:J
Last Name:YOUNGBEAR
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 CUSTER ST
Mailing Address - Street 2:APT 5
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520
Mailing Address - Country:US
Mailing Address - Phone:614-481-0683
Mailing Address - Fax:307-332-0131
Practice Address - Street 1:29 BLACK COAL DR
Practice Address - Street 2:
Practice Address - City:FORT WASHAKIE
Practice Address - State:WY
Practice Address - Zip Code:82514-0128
Practice Address - Country:US
Practice Address - Phone:307-332-7300
Practice Address - Fax:307-332-0131
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-10
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA125860163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY105726000Medicaid