Healthcare Provider Details

I. General information

NPI: 1720127145
Provider Name (Legal Business Name): SANDRA LEE JARVIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6255 TOWNCENTER DR STE 810
CLEMMONS NC
27012-9376
US

IV. Provider business mailing address

6255 TOWNCENTER DR STE 810
CLEMMONS NC
27012-9376
US

V. Phone/Fax

Practice location:
  • Phone: 980-533-0993
  • Fax:
Mailing address:
  • Phone: 980-533-0993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0050-00468
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number200017
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier70003712
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 2
IdentifierNP3666
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: