1174768485 NPI number — SANDRA DENNIS FNP

Table of content: SANDRA DENNIS FNP (NPI 1174768485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174768485 NPI number — SANDRA DENNIS FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DENNIS
Provider First Name:
SANDRA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174768485
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 688
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DYERSBURG
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38025-0688
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-476-9339
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1999 HIGHWAY 51 S
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38019-3630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-476-9339
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  APN13637 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Q003781 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 214846758 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09253832 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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