Healthcare Provider Details

I. General information

NPI: 1063736569
Provider Name (Legal Business Name): CHANTEL NICOLE SANFORD D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2010
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 LONGMAID DR
REISTERSTOWN MD
21136-6241
US

IV. Provider business mailing address

804 LONGMAID DR
REISTERSTOWN MD
21136-6241
US

V. Phone/Fax

Practice location:
  • Phone: 443-213-5900
  • Fax: 410-871-8721
Mailing address:
  • Phone: 443-213-5900
  • Fax: 410-871-8721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberE1-0000231
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO1000122
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number01571
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: