Healthcare Provider Details

I. General information

NPI: 1700033719
Provider Name (Legal Business Name): PENELOPE SANDIFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CHILDRENS DR
COLUMBUS OH
43205
US

IV. Provider business mailing address

700 CHILDRENS DR
COLUMBUS OH
43205-2664
US

V. Phone/Fax

Practice location:
  • Phone: 614-722-3553
  • Fax:
Mailing address:
  • Phone: 614-722-3553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number5315026494
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: