1992298012 NPI number — MS. SANDRA HARRISON RAKESTRAW RN, CDE

Table of content: MS. SANDRA HARRISON RAKESTRAW RN, CDE (NPI 1992298012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992298012 NPI number — MS. SANDRA HARRISON RAKESTRAW RN, CDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAKESTRAW
Provider First Name:
SANDRA
Provider Middle Name:
HARRISON
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RN, CDE
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:
1992298012
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
126 GRANT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDEN
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27288-5216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-613-0217
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 W STADIUM DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDEN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27288-3329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-627-4854
Provider Business Practice Location Address Fax Number:
336-627-8925
Provider Enumeration Date:
06/13/2018

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: 163WD0400X , with the licence number:  43121 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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