Healthcare Provider Details

I. General information

NPI: 1578402509
Provider Name (Legal Business Name): SANDRA ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SLEEPY DR
SPRING LAKE NC
28390-3317
US

IV. Provider business mailing address

91 FOUNTAIN PARK CIR
SPRING LAKE NC
28390-7002
US

V. Phone/Fax

Practice location:
  • Phone: 919-498-4207
  • Fax:
Mailing address:
  • Phone: 919-498-4207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: