Healthcare Provider Details

I. General information

NPI: 1760299986
Provider Name (Legal Business Name): SALLY ANN LORD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2024
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 N. CAUSEWAY STE. C
NEW SMYRNA BEACH FL
32169
US

IV. Provider business mailing address

161 N. CAUSEWAY STE. C
NEW SMYRNA BEACH FL
32169
US

V. Phone/Fax

Practice location:
  • Phone: 386-424-8440
  • Fax: 386-426-8839
Mailing address:
  • Phone: 386-424-8440
  • Fax: 386-426-8839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number10035005
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: