Healthcare Provider Details

I. General information

NPI: 1427066455
Provider Name (Legal Business Name): SANDRA J POLAND CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS SANDRA J PROVINES

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N. LORETTO RD
LEBANON KY
40033
US

IV. Provider business mailing address

PO BOX 5208
MERIDIAN MS
39302-5208
US

V. Phone/Fax

Practice location:
  • Phone: 270-699-2229
  • Fax:
Mailing address:
  • Phone: 601-703-9485
  • Fax: 601-703-9283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number3016943
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number899566
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: