Healthcare Provider Details

I. General information

NPI: 1740886704
Provider Name (Legal Business Name): CODY JO SANFORD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 N CENTRE ST
DE KALB TX
75559-1406
US

IV. Provider business mailing address

216 N CENTRE ST
DE KALB TX
75559-1406
US

V. Phone/Fax

Practice location:
  • Phone: 903-667-2273
  • Fax:
Mailing address:
  • Phone: 903-667-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number872128
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1029700
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: