MEDICARE: SANDISOVER ANNETTIE GRANT APRN

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	363L00000X	Nurse Practitioner	11044607	FL

General Provider Information

NPI Number	:	1962339440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDISOVER ANNETTIE GRANT APRN

Provider Business Mailing Address
First Line	:	PO BOX 919932
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32891-9932
Country	:	US
Telephone Number	:	904-493-3333
Fax Number	:	904-493-2222

Provider Business Practice Location Address
First Line	:	1465 KINGSLEY AVE
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-4504
Country	:	US
Telephone Number	:	904-644-0092
Fax Number	:

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

Provider Enumeration Date	:	05/07/2026
Last Update Date	:	06/05/2026

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