=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366509994
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRA KAY PONDER NURSE PRACTITIONER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3580 MORRISVILLE RD
-----------------------------------------------------
City | ANNISTON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36201-3955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-240-2386
-----------------------------------------------------
Fax | 256-240-9684
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 701 HUNTER LN SW
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36265-3721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-435-0330
-----------------------------------------------------
Fax | 256-435-0330
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1-036985
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------