1184015422 NPI number — MRS. ERIN SANDEFUR APRN

Table of content: MRS. ERIN SANDEFUR APRN (NPI 1184015422)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184015422 NPI number — MRS. ERIN SANDEFUR APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANDEFUR
Provider First Name:
ERIN
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
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:
1184015422
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1301 WHITE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATESVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72501-9467
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-307-8326
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 WHITE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATESVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72501-9467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-793-5504
Provider Business Practice Location Address Fax Number:
870-262-3253
Provider Enumeration Date:
02/09/2015

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:  A004295 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 210465758 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5BA31 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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