Provider Demographics
NPI:1033195953
Name:DURRETT, SANDRA C (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:C
Last Name:DURRETT
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:300 OXFORD ROAD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652
Practice Address - Country:US
Practice Address - Phone:662-534-8166
Practice Address - Fax:662-534-8132
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR803937363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122524Medicaid
302I503943Medicare Oscar/Certification
P09844Medicare UPIN