Healthcare Provider Details

I. General information

NPI: 1720103047
Provider Name (Legal Business Name): SALLY JO SANFORD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 LEGACY WAY STE B
ADAIRSVILLE GA
30103-2455
US

IV. Provider business mailing address

276 LITTLE RD NE
RESACA GA
30735-6522
US

V. Phone/Fax

Practice location:
  • Phone: 770-773-9902
  • Fax: 770-773-9803
Mailing address:
  • Phone: 706-625-7376
  • Fax: 770-773-9803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN072580
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: