Healthcare Provider Details

I. General information

NPI: 1477004349
Provider Name (Legal Business Name): ADRIENNE SANFORD OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 10/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S RIDGECREST AVE
NIXA MO
65714-7807
US

IV. Provider business mailing address

105 S RIDGECREST AVE
NIXA MO
65714-7807
US

V. Phone/Fax

Practice location:
  • Phone: 417-725-8250
  • Fax:
Mailing address:
  • Phone: 417-725-8250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2008013379
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: