Healthcare Provider Details

I. General information

NPI: 1962339440
Provider Name (Legal Business Name): SANDISOVER ANNETTIE GRANT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 KINGSLEY AVE
ORANGE PARK FL
32073-4504
US

IV. Provider business mailing address

PO BOX 919932
ORLANDO FL
32891-9932
US

V. Phone/Fax

Practice location:
  • Phone: 904-644-0092
  • Fax:
Mailing address:
  • Phone: 904-493-3333
  • Fax: 904-493-2222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11044607
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: