Healthcare Provider Details

I. General information

NPI: 1497659775
Provider Name (Legal Business Name): STACEY DIANE SANFORD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3023 DUPORTAIL ST STE C
RICHLAND WA
99352-6103
US

IV. Provider business mailing address

2313 OLYMPIA ST
RICHLAND WA
99354-3042
US

V. Phone/Fax

Practice location:
  • Phone: 209-450-6833
  • Fax:
Mailing address:
  • Phone: 509-420-9178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP70032417
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: