Healthcare Provider Details

I. General information

NPI: 1225188196
Provider Name (Legal Business Name): LISA ANN SANFORD MSN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 03/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3305 SUNGATE BLVD
RALEIGH NC
27610-2871
US

IV. Provider business mailing address

125 TALLY HO DR
SELMA NC
27576-8451
US

V. Phone/Fax

Practice location:
  • Phone: 919-212-0129
  • Fax: 919-255-1540
Mailing address:
  • Phone: 919-965-4459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number105289
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: