MEDICARE: SANDRA ELLIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374700000X	Technician		NC

General Provider Information

NPI Number	:	1578402509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA ELLIS

Provider Business Mailing Address
First Line	:	91 FOUNTAIN PARK CIR
Second Line	:
City	:	SPRING LAKE
State	:	NC
Zip	:	28390-7002
Country	:	US
Telephone Number	:	919-498-4207
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 SLEEPY DR
Second Line	:
City	:	SPRING LAKE
State	:	NC
Zip	:	28390-3317
Country	:	US
Telephone Number	:	919-498-4207
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2026
Last Update Date	:	03/26/2026

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