Healthcare Provider Details

I. General information

NPI: 1760423859
Provider Name (Legal Business Name): SANDI L DISTEFANO CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SANDI L ANGELLO-SOTO CRNA

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 ROCK MERRITT AVE
FORT BRAGG NC
28310-0001
US

IV. Provider business mailing address

2817 ROCK MERRITT AVE
FORT BRAGG NC
28310-0001
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-8707
  • Fax: 910-715-1943
Mailing address:
  • Phone: 910-907-8707
  • Fax: 910-715-1943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number154344
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: