Healthcare Provider Details

I. General information

NPI: 1104107226
Provider Name (Legal Business Name): SANDRA JEAN FORD MSN, RN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2011
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12832 NW CENTRAL AVE
BRISTOL FL
32321-6918
US

IV. Provider business mailing address

403 E 11TH ST
PANAMA CITY FL
32401-3409
US

V. Phone/Fax

Practice location:
  • Phone: 850-643-2292
  • Fax: 850-643-2306
Mailing address:
  • Phone: 850-643-2292
  • Fax: 850-643-2306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9365955
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA03599
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: